Your assessment of M.N. finds her with decreased breath sounds and crackles in the right base posteriorly. Her right middle and lower lobes percuss slightly dull. She splints her right side when attempting to take a deep breath. Her skin is pale, warm, an

Question

What complication do you suspect M.N. is experiencing? State your rationale.

Why is M.N. at risk for developing this complication?

What is your nursing priority at this time?

Describe six interventions you will perform over the next few hours based on this priority.

To promote optimal oxygenation with M.N., which action(s) could you delegate to the NAP?
Select all that apply.
a. Reminding M.N. to cough and deep breathe
b. Instructing M.N. on the use of incentive spirometry
c. Assisting M.N. in getting up to the chair
d. Taking M.N.'s temperature and reporting elevations
e. Encouraging M.N. to splint the incision
f. Auscultating M.N.'s lung sounds

Identify three outcomes that you expect for M.N. as a result of your interventions.

Answer 1

M.N. appears to be developing atelectasis. She has the common presenting symptoms of dyspnea
and hypoxia, accompanied by fever, crackles, and diminished breath sounds. Pneumonia typically
does not occur this early; the common signs of pulmonary embolism M.N. does not have include
anxiety, pleuritic chest pain, cyanosis, and hypoxia.

The effects of anesthesia, reluctance to cough and deep breathe because of inadequate pain control
and location of the surgical incision, and immobility contribute to the inadequate lung expansion
that predisposes patients to developing atelectasis.

The nursing priority right now is to improve M.N.'s respiratory status.

• Apply the oxygen per protocol because her Spo2 is below 95%.
• Elevate the head of her bed.
• Administer pain medication if the time interval is appropriate. Tell her that you are going to let her
rest for 20 minutes until the morphine has had time to take effect; then you will be back to help her
dangle, use the incentive spirometer (IS), and cough and deep breathe.
• Have her cough and deep breathe every hour, splinting her incision. If needed, review with her
appropriate technique and coach her while she coughs.
• Explain and demonstrate the correct use of the IS. Have her use the IS every hour while awake.
• Have her dangle on the side of the bed as ordered.
• Turn and reposition every 2 hours.
• Reassess her vital signs every 2 hours and monitor for signs of deterioration.
• Be prepared to call a physician if her condition worsens.

Answers: a, c, d, e
To prevent pulmonary complications, patients should be encouraged to cough and deep breathe,
ambulate as soon as possible, and splint the incision to minimize discomfort during activity. For
patient safety, the nurse should enlist the assistance of other staff members, including the NAP,
during these efforts, while encouraging the patient to help. The NAP cannot instruct the patient on
the use of the IS; teaching is the responsibility of the registered nurse (RN); however, the NAP could
reinforce teaching provided by the RN. The NAP can take the patient's vital signs as long as the
RN has given the NAP parameters that the NAP would need to report to the RN. Auscultating lung
sounds is not within the scope of practice for the NAP.

• Decreased resting respiratory rate
• Increased breath sounds over the right lower lobe by auscultation
• Crackles clearing or clear lung sounds
• Spo2 greater than 90%
• Afebrile status
• Resonant percussion