A nurse is caring for a patient at risk for atelectasis.
Which independent nursing measure should the nurse prioritize to prevent the development of atelectasis?
Ambulation.
Oxygen therapy.
Incentive spirometry.
Increase oral fluid intake.
The Correct Answer is C
Choice A rationale
Ambulation is a general measure that can help improve overall lung function by promoting deep breathing, coughing, and mobilization of secretions. However, it is not the primary measure to prevent atelectasis.
Choice B rationale
Oxygen therapy is used to treat hypoxia, which can be a result of atelectasis. However, it does not directly prevent the development of atelectasis.
Choice C rationale
Incentive spirometry is a first-line measure to prevent atelectasis. It encourages deep breathing, which helps keep the alveoli inflated and can prevent them from collapsing, thus preventing atelectasis.
Choice D rationale
Increasing oral fluid intake can help to thin secretions, making them easier to mobilize. However, it is not the primary measure to prevent atelectasis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
Choice A rationale
Using chewing tobacco every day is a significant risk factor for laryngeal cancer. Tobacco contains many carcinogens, which can damage the cells in the larynx and lead to cancer.
Choice B rationale
Being an industrial-commercial painter is associated with an increased risk of laryngeal cancer. This is likely due to exposure to certain chemicals and toxins that are used in paints and other materials.
Choice C rationale
Being an ultrasound technician is not typically associated with an increased risk of laryngeal cancer. Ultrasound technicians are not generally exposed to the types of toxins or risk factors that are associated with laryngeal cancer.
Choice D rationale
Wearing magnetic healing bracelets is not associated with an increased risk of laryngeal cancer. There is no scientific evidence to suggest that these bracelets have any effect on cancer risk.
Choice E rationale
Having a spouse who smokes cigarettes is a risk factor for laryngeal cancer. Secondhand smoke, also known as passive smoke, contains many of the same carcinogens as the smoke inhaled by smokers. Exposure to secondhand smoke can increase a person’s risk of developing laryngeal cancer.
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale
A PTT of 70 seconds (control 25-40) indicates that the patient’s blood is taking longer than normal to clot, which could increase the risk of bleeding. This could be a sign of excessive anticoagulation from the Heparin infusion.
Choice B rationale
Ecchymosis at the venipuncture site could be a sign of bleeding under the skin, which could indicate that the patient is receiving too much Heparin.
Choice C rationale
Hematuria, or blood in the urine, could be a sign of bleeding in the urinary tract, which could be a side effect of Heparin therapy.
Choice D rationale
If there is an order for Coumadin 2.5 mg to start today, the healthcare provider should be notified. Coumadin and Heparin are both anticoagulants, and using them together could increase the risk of bleeding.
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