A nurse is reinforcing teaching about how to use an incentive spirometer with a client. Which of the following statements should the nurse make?

"Inhale through the incentive spirometer 10 times with each use."

"Use the incentive spirometer once every 4 hours."

"Sit up at a 30-degree angle when using the incentive spirometer."

"Hold your breath for 7 seconds when using the incentive spirometer."

Answer and Explanation

The Correct Answer is A

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Correct Answer is C

Explanation

A. Bradycardia:
Explanation: Bradycardia refers to a slow heart rate. In hypervolemia (fluid overload), the heart often compensates by increasing the heart rate rather than causing bradycardia.

B. Oliguria:
Explanation: Oliguria refers to decreased urine output. In hypervolemia, the increased fluid volume can lead to increased urine output rather than oliguria.

C. Peripheral Edema:
Explanation: Peripheral edema, or swelling in the extremities, is a common manifestation of hypervolemia. Excess fluid can accumulate in the tissues.

D. Hypotension:
Explanation: Hypertension, not hypotension, is more commonly associated with hypervolemia. The increased volume of fluid in the blood vessels can lead to elevated blood pressure.

A. Identify the clients at greatest risk for development of pressure ulcers. B. Turn and position each client every 2 hr. C. Use a barrier cream when performing perineal care. D. Supervise clients to ensure adequate nutritional intake.

Correct Answer is A

Explanation

A. Identify the clients at greatest risk for the development of pressure ulcers.
This option emphasizes the importance of individualized care. By identifying clients at the highest risk for pressure ulcers, healthcare providers can tailor preventive measures to address specific risk factors such as immobility, nutritional deficits, and skin conditions.

B. Turn and position each client every 2 hr.
Regular turning and repositioning are crucial in preventing pressure ulcers, especially in individuals with limited mobility. This helps distribute pressure, reducing the risk of skin breakdown. However, this alone may not be sufficient if other risk factors are not addressed.

C. Use a barrier cream when performing perineal care.
Barrier creams can be helpful in protecting the skin from moisture and friction, especially in areas prone to pressure ulcers. While this is a good practice, it may not be the top priority compared to identifying those at the highest risk.

D. Supervise clients to ensure adequate nutritional intake.
Proper nutrition plays a vital role in maintaining skin integrity. Malnutrition can contribute to the development of pressure ulcers. Monitoring and ensuring adequate nutritional intake are important components of prevention but may not be the initial priority.

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A nurse is reinforcing teaching about how to use an incentive spirometer with a client. Which of the following statements should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data on a client who is experiencing hypervolemia. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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