The nurse is caring for a client at risk for atelectasis. The nurse implements a first- line measure to prevent atelectasis development in the client. What is an example of a first-line measure to minimize atelectasis?

Positive end-expiratory pressure (PEEP)

Intermittent positive-pressure breathing (IPPB)

Incentive spirometry

Bronchoscopy

Answer and Explanation

The Correct Answer is C

A. Positive end-expiratory pressure (PEEP): PEEP is used in mechanical ventilation to prevent atelectasis, but it's not a first-line approach for non-ventilated patients. It's used more in critical care settings.

B. Intermittent positive-pressure breathing (IPPB): IPPB helps with lung expansion but is not a standard first-line method. It's more used for specific cases requiring enhanced lung expansion.

C. Incentive spirometry: Incentive spirometry is the first-line measure for preventing atelectasis, especially in post-surgical or immobile patients. It promotes deep breathing and alveolar expansion, helping prevent lung collapse.

D. Bronchoscopy: Bronchoscopy is used for diagnostic or therapeutic purposes, like clearing airway obstructions, but it's not a preventive measure for atelectasis. It’s a more invasive intervention when necessary.

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Correct Answer is C

Explanation

A. Copious oral secretions: Copious oral secretions may occur after the removal of the endotracheal tube, especially if the client is still recovering from anesthesia. While concerning, this is not as immediately dangerous as stridor and can often be managed with suctioning.

B. Hoarseness: Hoarseness is a common and expected finding after extubation. It may result from irritation of the vocal cords or the trauma caused by the endotracheal tube. This is generally not an urgent issue and can resolve over time.

C. Stridor: Stridor is a high-pitched, wheezing sound that indicates upper airway obstruction. It is a serious sign of respiratory distress and requires immediate intervention. Stridor can be caused by swelling or laryngeal injury after extubation and should be reported immediately.

D. Sore throat: A sore throat is a common side effect of endotracheal tube placement and is typically not a cause for immediate concern. It usually resolves within a few days and does not require urgent reporting unless accompanied by other alarming symptoms.

A. A room with air exhaust directly to the outdoor environment B. A room in the ICU C. A room that is within view of the nurses' station D. A room with another nonsurgical client

Correct Answer is A

Explanation

A. A room with air exhaust directly to the outdoor environment: TB is a contagious airborne disease, and the client should be placed in a negative pressure room with an air exhaust system that directs air outside the building. This prevents the spread of the airborne pathogen to other areas in the hospital.

B. A room in the ICU: While a client with active TB may require ICU care depending on the severity of their condition, being placed in the ICU is not required solely due to the TB diagnosis. The priority is to place them in a room with appropriate airborne precautions.

C. A room that is within view of the nurses' station: While it is important to monitor the client closely, the priority for this client is to ensure they are in a room with proper ventilation and isolation to prevent the spread of the infection. The visibility of the room is secondary to infection control measures.

D. A room with another nonsurgical client: A client with active TB should not be placed in the same room as another client, unless both are infected with TB. TB is contagious, and the client should be isolated to prevent transmission to others.

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The nurse is caring for a client at risk for atelectasis. The nurse implements a first- line measure to prevent atelectasis development in the client. What is an example of a first-line measure to minimize atelectasis?

Nursing Test Bank

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