An RN is caring for a patient after surgery.
Which of the following nursing interventions should the RN implement to prevent atelectasis? Select all that apply.

Rationale for Correct Condition

Congestive heart failure (CHF) exacerbation is characterized by fluid overload leading to dyspnea, jugular vein distention, crackles, and rapid weight gain. The client’s worsening respiratory distress, bilateral lung crackles, tachypnea, and history of heart disease strongly indicate CHF rather than COPD exacerbation, pneumonia, or pneumothorax.

Rationale for Correct Actions

Elevating the head of the bed reduces pulmonary congestion by improving lung expansion and decreasing venous return, alleviating dyspnea. Applying oxygen at 6 L/min via nasal cannula enhances oxygenation by addressing hypoxia and improving tissue perfusion in the presence of pulmonary congestion.

Rationale for Correct Parameters

Oxygen saturation reflects pulmonary function and cardiac output, guiding oxygen therapy adjustments and determining hypoxia severity. Respiratory rate indicates the extent of respiratory distress, compensatory mechanisms for hypoxia, and the effectiveness of interventions.

Rationale for Incorrect Conditions

COPD exacerbation would typically involve wheezing, prolonged expiration, and severe airway obstruction. Pneumonia presents with fever, localized crackles, and productive cough, which are absent. Spontaneous pneumothorax causes sudden onset chest pain, absent breath sounds, and asymmetric lung expansion.

Rationale for Incorrect Actions

Smoking cessation program is beneficial long-term but does not address acute CHF symptoms. Asking about food intake is unrelated to managing pulmonary congestion. Applying oxygen at 2 L/min may not be sufficient for severe dyspnea; higher-flow oxygen is needed.

Rationale for Incorrect Parameters

WBC count monitors infection, which is not the primary concern in CHF. Temperature evaluates systemic infection, not fluid overload. Arterial blood gases provide respiratory status but are not routinely needed in CHF unless respiratory failure is suspected.

Choice A rationale

Limiting exercise to 10 minutes, 2 days per week is insufficient for cardiovascular health. Current recommendations generally advise at least 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous-intensity aerobic activity per week, along with muscle-strengthening activities at least two days a week, to reduce the risk of heart disease.

Choice B rationale

Monitoring blood pressure is a crucial preventative measure for heart disease. Hypertension is a major risk factor for cardiovascular diseases, including coronary artery disease, stroke, and heart failure. Regular blood pressure monitoring allows for early detection and management of elevated blood pressure, reducing the risk of these complications. A normal blood pressure is typically considered to be less than 120/80 mmHg.

Choice C rationale

Losing weight if necessary is an important recommendation for preventing heart disease. Obesity and being overweight are significant risk factors for hypertension, dyslipidemia, type 2 diabetes, and sleep apnea, all of which increase the risk of heart disease. Achieving and maintaining a healthy weight through diet and exercise can significantly reduce cardiovascular risk.

Choice D rationale

Eating a diet high in saturated fats increases the risk of heart disease. Saturated fats can raise low-density lipoprotein (LDL) cholesterol levels, which contribute to the formation of atherosclerotic plaques in the arteries, increasing the risk of coronary artery disease and stroke. Dietary guidelines recommend limiting saturated fat intake.

Choice E rationale

Maintaining the current cholesterol level may not be a preventative measure if the current cholesterol level is elevated. High levels of LDL cholesterol are a major risk factor for heart disease. Preventative measures often include lifestyle modifications and, if necessary, medication to lower elevated cholesterol levels to reduce cardiovascular risk. Normal total cholesterol is generally less than 200 mg/dL, LDL cholesterol less than 100 mg/dL, and HDL cholesterol greater than 60 mg/dL.