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."
The Correct Answer is C
A. "Inhale through the incentive spirometer 10 times with each use."
Explanation: The specific number of breaths can vary, and it's essential to follow the healthcare provider's or manufacturer's instructions. The emphasis is on taking slow, deep breaths rather than a specific count.
B. "Use the incentive spirometer once every 4 hours."
Explanation: The frequency of use may vary based on the healthcare provider's recommendations, the client's condition, and the healthcare setting. It's crucial to follow the individualized plan of care.
C. "Sit up at a 30-degree angle when using the incentive spirometer."
Explanation: This is correct. The client should sit upright to maximize lung expansion while using the incentive spirometer.
D. "Hold your breath for 7 seconds when using the incentive spirometer."
Explanation: The emphasis is on slow, deep inhalation rather than holding the breath for a specific duration. The primary goal is to improve lung function and prevent atelectasis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Apply Neosporin to avoid infection:
This choice suggests applying Neosporin to the surgical site. However, the immediate postoperative care for cleft lip surgery often involves keeping the incision site covered with sterile dressings. Topical antibiotics may be prescribed by the healthcare provider if deemed necessary, but it's not a routine application without specific instructions.
B. Apply elbow immobilizers when not being held:
This choice implies using elbow immobilizers for the child. However, elbow immobilizers are not a standard intervention for cleft lip surgery. The focus is usually on keeping the surgical site clean and preventing complications like infection.
C. Suction secretions away from the suture line:
This is the recommended choice. Suctioning helps maintain a clear airway and prevents secretions from affecting the surgical site. It's a crucial step in the immediate postoperative period.
D. Feed increased amounts of formula to prevent weight loss:
While feeding is an essential aspect of care, especially for nutritional support, the immediate concern in the first few days after cleft lip surgery is often related to maintaining a patent airway and preventing infection. Feeding interventions might be guided by the healthcare provider's recommendations, but it's not the primary focus in the initial postoperative period.
Correct Answer is D
Explanation
Correct answer: D
A.While it is important to ensure the can of formula is clean, it should be wiped with soap and water or a disinfectant wipe, not an alcohol wipe.
B.Cold formula can cause gastric discomfort or cramping. It's recommended to bring the formula to room temperature before administration to avoid gastric irritation and enhance comfort during feeding.
C.The action of withholding the feeding depends on the institution's protocol and the specific clinical condition of the client. Typically, residuals greater than 200 mL might indicate delayed gastric emptying, but the threshold can vary. A residual volume of 150 mL may not necessarily require withholding the feeding, though it may warrant further assessment.
D.It is standard practice to flush the NG tube with 30 mL of sterile water (or as per facility guidelines) before administering an enteral feeding. This helps ensure the tube is patent, reduces the risk of clogging, and ensures the feeding formula flows smoothly. Flushing before the feeding also helps clear the tube of any residual formula, preventing cross-contamination.
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