The nurse caring for a 38-year-old female client with multiple fractur

The nurse caring for a 38-year-old female client with multiple fractures in the trauma intensive care unit knows that this client is at high risk for pulmonary complications such as atelectasis from her immobility.

One of the interventions that the nurse can do to help prevent this from occurring is to:
1. Keep the PaO2 level at or above 94%
2. Instruct the client to deep breathe and cough every hour while awake
3. Turn the client every 2 hours
4. Keep the client on the ventilator as long as possible

ANSWER

ANS: 2
In atelectasis, secretions block a bronchiole or a bronchus, and the distal lung tissue (alveoli) col-lapses as the existing air is absorbed, producing hypoventilation. The site of the blockage affects the severity of atelectasis. Sometimes an entire lung lobe or a whole lung collapses. At some point in the development of these complications, there is a proportional decline in the client’s ability to cough productively. Turning the client is an excellent way to help prevent the accumulation of mucus in the dependent regions of the airways causing hypostatic pneumonia. Mucus is an excel-lent place for bacteria to grow. Keeping a client on a ventilator longer than necessary has the po-tential to cause multiple other complications and is not the best choice.