A nurse is assisting with the care of a client.

Exhibits
Which of the following actions should the nurse take to promote the client's respiratory status? Select all that apply.

Encourage the client to splint the abdomen when coughing.

Administer acetaminophen.

Administer ondansetron.

Remind the client to use the incentive spirometer five times per hr.

Encourage the client to cough and deep breathe.

Plan to ambulate the client 30 min after the next analgesic is administered.

Answer and Explanation

Correct Answer : A,D,E,F

A. Splinting the abdomen helps reduce pain during coughing, making it easier for the client to take deep breaths and effectively clear secretions. This is particularly important after abdominal surgery to minimize discomfort and promote effective coughing.

B. While acetaminophen can help with pain relief, it does not directly address the respiratory status of the client. Therefore, it is not a priority action in this context.

C. Ondansetron is effective for managing nausea, but it does not contribute to improving respiratory status directly. It is necessary for comfort, but it is not an action that promotes respiratory function.

D. The incentive spirometer is a valuable tool for encouraging deep breathing, which helps expand the lungs, improve ventilation, and prevent atelectasis (lung collapse). Regular use of the spirometer is crucial, especially in postoperative clients with decreased mobility.

E. Coughing and deep breathing are essential practices to prevent respiratory complications. They help clear secretions and promote lung expansion, which can improve oxygenation and respiratory function.

F. Ambulation is important for improving respiratory status by promoting lung expansion and circulation. It also aids in preventing complications such as deep vein thrombosis (DVT) and pneumonia. Planning ambulation after administering analgesics ensures that the client is more comfortable and able to participate in this activity.

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Correct Answer is C

Explanation

A. It is not necessary for the client to remain supine for 10 minutes after administering otic medication. Typically, only a few minutes are needed to ensure the medication stays in the ear canal.

B. Pulling the pinna downward and back is the correct technique for children. For adults, the pinna should be pulled upward and back to straighten the ear canal.

C. Holding the ear dropper 1 cm from the ear prevents contamination while allowing for precise medication administration into the ear canal.

D. Cleansing the ear with isopropyl alcohol can cause irritation and is not generally required prior to otic medication administration.

A. Repeat the test three times using the same stool specimen. B. Wear sterile gloves when handling the stool specimen. C. Have the client defecate into a bedpan that contains a small amount of water. D. Ensure that the stool specimen does not contain urine.

Correct Answer is D

Explanation

A. Repeating the test typically requires separate samples over different days, not the same specimen.

B. Clean gloves, not sterile gloves, are sufficient when handling stool specimens.

C. Collecting the sample with a dry bedpan is preferable; water can dilute the specimen.

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A nurse is assisting with the care of a client. Exhibits Which of the following actions should the nurse take to promote the client's respiratory status? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to instill an otic medication for an adult client. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is preparing to perform a fecal occult blood test of stool specimens for a client. Which of the following actions should the nurse plan to take?

Correct Answer is D

Explanation

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A nurse is assisting with the care of a client.

Exhibits
Which of the following actions should the nurse take to promote the client's respiratory status? Select all that apply.