The nursing student is reviewing interventions which are part of nursing care and prevention of atelectasis. What are some of the interventions nurses can do to prevent atelectasis? (SELECT ALL THAT APPLY)
Administer antibiotics
Encourage increased oral fluid intake
Early mobilization after surgery
Frequent turning of the patient
Use of incentive spirometry
Correct Answer : B,C,D,E
A. Administer antibiotics
Administering antibiotics is not a direct intervention for preventing atelectasis. Antibiotics are typically prescribed to treat bacterial infections, and atelectasis is more related to lung collapse or incomplete lung expansion.
B. Encourage increased oral fluid intake
Adequate hydration is important for maintaining the moisture of respiratory secretions. This helps prevent mucus from becoming thick and sticky, making it easier for the patient to cough and clear the airways.
C. Early mobilization after surgery
Early mobilization, including activities such as getting out of bed and walking, helps improve lung expansion. It promotes better ventilation and prevents areas of the lungs from collapsing, reducing the risk of atelectasis.
D. Frequent turning of the patient
Turning the patient regularly is crucial for preventing pooling of respiratory secretions in dependent areas of the lungs. By changing the patient's position, nurses can facilitate drainage and ventilation throughout the lungs, minimizing the risk of atelectasis.
E. Use of incentive spirometry
Incentive spirometry is a breathing exercise device that encourages the patient to take slow, deep breaths. This helps expand the lungs and prevents atelectasis by maintaining lung volume and promoting alveolar recruitment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Coronary artery disease (CAD):
Coronary artery disease primarily affects the blood vessels supplying the heart muscle. Symptoms often include chest pain (angina) rather than pain in the lower extremities. The symptoms described in the scenario are not characteristic of CAD.
B. Arterial embolus:
An arterial embolus is a blood clot or debris that travels through the bloodstream and can block an artery. While it can cause decreased blood flow and pain, the presentation in the lower left leg and foot with relief of pain at rest is more suggestive of peripheral arterial disease (PAD) or intermittent claudication rather than an acute arterial embolus.
C. Raynaud disease:
Raynaud's disease is characterized by episodes of reduced blood flow to the extremities, usually triggered by cold or stress. It typically involves color changes (white, blue, red) in the fingers or toes. The symptoms described, including pain in the lower leg and foot during walking, are not typical of Raynaud's disease.
D. Intermittent claudication:
Intermittent claudication is a symptom associated with peripheral arterial disease (PAD). It involves pain or cramping in the legs during physical activity, such as walking, due to reduced blood flow to the muscles. Rest typically relieves the pain. The observation of a hairless leg and slight edema suggests potential vascular compromise in the lower extremity, supporting the diagnosis of intermittent claudication.
Correct Answer is C
Explanation
A. Partial non-rebreathing mask:
This mask delivers higher concentrations of oxygen than a nasal cannula. It has a reservoir bag that allows the client to rebreathe some exhaled air, increasing the oxygen concentration delivered. However, it may not be necessary for a client with mild shortness of breath and slightly reduced oxygen saturation.
B. Simple (Oxy Plus) mask:
The simple mask provides a higher concentration of oxygen than a nasal cannula but lacks the reservoir bag found in the non-rebreathing mask. It is generally used for moderate oxygen needs. However, it might be more than what is required for a client with mild shortness of breath and slightly reduced oxygen saturation.
C. Nasal cannula:
Nasal cannulas are commonly used for clients with mild respiratory distress. They deliver a lower to moderate concentration of oxygen and are well-tolerated by most clients. They are suitable for individuals with mild shortness of breath and can be adjusted based on the required flow rate.
D. Non-rebreathing mask:
The non-rebreathing mask provides the highest concentration of oxygen among the options listed. It includes a reservoir bag to deliver a higher oxygen concentration. It is typically reserved for clients with higher oxygen requirements. For a client with mild shortness of breath and slightly reduced oxygen saturation, this may be more than necessary.
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