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Which interventions prevent or treat atelectasis? Select all that apply.

Encourage ambulation if allowed out of bed by health care provider.

Encourage postoperative clients to cough and deep breathe.

Maintain clients in a supine position at all times to prevent aspiration.

Educate patient to blow into the incentive spirometer every 2 hours.

Allow clients who recently had a stroke to feed themselves to promote self-care.

Educate patient to inhale slow and deep with lips tight around the mouth piece of the incentive spirometer.

Answer and Explanation

Correct Answer : A,B,F

Choice A rationale

Ambulation is a critical intervention for preventing atelectasis because physical movement encourages deeper breathing and the expansion of the lungs. Walking increases the tidal volume and helps mobilize secretions that might otherwise collect in the lower lobes and cause alveolar collapse. By shifting the patient’s position and increasing metabolic demand slightly, ambulation promotes better ventilation-perfusion matching throughout the pulmonary system. It is one of the most effective non-invasive ways to maintain lung health postoperatively.

Choice B rationale

Encouraging coughing and deep breathing is a standard nursing intervention to prevent the collapse of small airways and alveoli. Deep breathing exercises increase the pressure within the lungs, helping to pop open collapsed alveoli through collateral ventilation. Coughing provides the necessary force to move mucus from the smaller airways into the larger ones where it can be expectorated. This reduces the risk of mucus plugging, which is a primary cause of obstructive atelectasis in surgical patients.

Choice C rationale

Maintaining a client in a supine position at all times is actually a risk factor for atelectasis rather than a prevention strategy. When a patient lies flat, the abdominal contents push upward against the diaphragm, and gravity causes the posterior lung fields to be compressed. This restricts full lung expansion and leads to the collapse of the dependent alveoli. Frequent repositioning and elevating the head of the bed are preferred to ensure maximal lung expansion and better gas exchange.

Choice D rationale

This choice is incorrect because the incentive spirometer is designed for inhalation, not exhalation. Educating a patient to blow into the device would not achieve the goal of alveolar expansion. The purpose of the incentive spirometer is to provide visual feedback as the patient takes a slow, deep breath in, which creates sustained maximal inspiration. This process increases transpulmonary pressure and helps re-expand collapsed lung tissue. Blowing into the device would be ineffective for treating atelectasis.

Choice E rationale

While promoting self-care is important for stroke rehabilitation, allowing a patient with a recent stroke to feed themselves without supervision is a safety risk regarding aspiration. Aspiration can lead to pneumonia or focal atelectasis if foreign material enters the bronchial tree. This intervention does not directly target the mechanical expansion of the alveoli or the prevention of lung collapse. Furthermore, stroke patients often have dysphagia, making unmonitored feeding a dangerous practice rather than a preventive lung intervention.

Choice F rationale

Proper technique for using an incentive spirometer involves creating a tight seal around the mouthpiece and inhaling slowly and deeply. A slow, sustained inhalation is necessary to ensure that the air reaches the most distal parts of the lungs, including the alveoli that are at risk of collapsing. The goal is to reach a target volume and hold the breath for several seconds to maximize the recruitment of lung tissue. This specific educational point is essential for effective treatment.

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Correct Answer is D

Explanation

Choice A rationale

Metabolic acidosis is characterized by a primary decrease in bicarbonate or an accumulation of nonvolatile acids in the blood. While patients with severe illness can develop multiple imbalances, the primary issue in COPD is not metabolic in origin. In metabolic acidosis, the lungs typically respond by hyperventilating to blow off carbon dioxide to raise the pH. This is the opposite of the hypoventilation and carbon dioxide retention typically seen in patients with chronic obstructive pulmonary disease.

Choice B rationale

Respiratory alkalosis occurs when there is excessive elimination of carbon dioxide from the lungs, usually due to hyperventilation. This leads to an increase in blood pH levels above 7.45. In a client with severe COPD, the primary physiological challenge is the inability to exhale carbon dioxide effectively due to air trapping and alveolar destruction. Therefore, these patients are much more likely to retain carbon dioxide rather than eliminate too much of it through the respiratory system.

Choice C rationale

Metabolic alkalosis involves a primary increase in bicarbonate levels or a loss of metabolic acids, leading to a blood pH greater than 7.45. This condition can be caused by factors like prolonged vomiting or excessive diuretic use. While some COPD patients on certain medications might experience metabolic shifts, it is not the classic acid-base imbalance associated with the underlying pathophysiology of obstructive lung disease and the resulting chronic failure of the respiratory pump to clear gas.

Choice D rationale

Respiratory acidosis is the hallmark of severe COPD due to chronic airflow obstruction and impaired gas exchange. The damaged alveoli and narrowed airways lead to the retention of carbon dioxide, which is a physiological acid. As carbon dioxide levels rise above the normal range of 35 to 45 mmHg, the blood pH drops below 7.35. This client’s report of dyspnea with minimal exertion suggests a high level of CO2 retention and a state of chronic respiratory acidosis.

A. Oxygen tank. B. CPAP machine. C. Incentive spirometer. D. Pulse oximeter.

Correct Answer is B

Explanation

Choice B rationale

Obstructive sleep apnea (OSA) is characterized by the repetitive collapse of the upper airway during sleep, leading to periods of apnea and hypoxemia. A Continuous Positive Airway Pressure (CPAP) machine is the gold-standard treatment for OSA. It delivers a constant stream of pressurized air through a mask, which acts as a physical splint to keep the airway open. The nurse would expect this device to be present at the bedside for use whenever the client sleeps.

Choice A rationale

While supplemental oxygen may be used in some respiratory conditions, it is not the primary or standard treatment for obstructive sleep apnea. In OSA, the problem is a mechanical blockage of the airway, not necessarily a lack of ambient oxygen. Providing oxygen through a tank or concentrator without addressing the airway collapse does not prevent the apneic episodes. The CPAP is the specific tool designed to overcome the physiological obstruction that defines this specific sleep disorder.

Choice C rationale

An incentive spirometer is used to encourage deep breathing and prevent atelectasis, typically in postoperative patients or those with pneumonia. It helps expand the alveoli and clear secretions. However, it is a voluntary exercise performed while awake and does nothing to prevent the airway collapse that occurs during sleep in patients with OSA. While it is a common bedside respiratory tool, it is not a specific or indicated treatment for managing obstructive sleep apnea.

Choice D rationale

A pulse oximeter is a diagnostic tool used to monitor oxygen saturation, but it is not a treatment device. While a nurse might use a pulse oximeter to assess the severity of desaturation during sleep apnea events, the question asks for a device used to manage the condition. The pulse oximeter provides data but does not provide the therapeutic intervention needed to keep the airway patent. The CPAP machine is the therapeutic device expected for this diagnosis.

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Which interventions prevent or treat atelectasis? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the ABG values of a client who has severe COPD, uses 1 liter of oxygen via nasal cannula, and reports dyspnea with minimal exertion. Which acid-base imbalance should the nurse suspect?

Correct Answer is D

Explanation

The nurse is caring for a client who has a history of obstructive sleep apnea. The nurse would expect to see which device at the client's bedside?

Correct Answer is B

Explanation

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