QBank Test - Nursing Education

Following an industrial accident, the patient is immobile. The student nurse is creating a care plan for the patient to prevent respiratory decompensation. Which intervention, if included in the care plan for this nursing diagnosis, would prompt the nurse to provide additional education to the student nurse?

Correct

Encourage fluid intake
Turn patient every 2 hours
Limit cigarette smoking to 2 cigarettes per day
Instruct the patient on the use of the incentive spirometer

Rationale

The patient at risk for respiratory decompensation related to immobility after an accident should not smoke at all. Nicotine replacement therapy may be necessary to help the patient avoid smoking entirely. Increased fluid intake helps maintain thin secretions that are easy to cough up. Turning the patient every two hours helps with fluid mobilization and prevention of atelectasis. The incentive spirometer exercises respiratory muscles and helps to prevent atelectasis, as well.

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