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. To confirm the placement of the NG tube:
Confirming NG tube placement is typically done using other methods, such as auscultation of air insufflation, pH testing, or X-ray. Gastric residual measurement helps assess the status of the stomach content but is not the primary method for confirming tube placement.
B. To determine the client's electrolyte balance:
While the gastric contents do contain electrolytes, the primary purpose of measuring gastric residual is to assess gastric emptying and potential feeding intolerance. It is not the most accurate method for determining overall electrolyte balance.
C. To identify delayed gastric emptying:
This is the correct and primary purpose. Measuring gastric residual helps in identifying if there's a delay in the stomach emptying the previously administered feeding, which can inform the nurse about the client's tolerance to enteral nutrition.
D. To remove gastric acid that might cause dyspepsia:
The process of measuring gastric residual doesn't involve removing gastric acid. It's more about assessing how much of the previously administered feeding remains in the stomach. If there's a high residual volume, it may suggest delayed emptying or feeding intolerance. The focus is on adjusting the feeding plan rather than removing gastric acid.
Correct Answer is ["C","D"]
Explanation
A. The patient uses crutches with a swing-to gait.
This action doesn't necessarily indicate a concern after hip arthroplasty. However, the nurse might want to assess the patient's gait and the use of crutches to ensure the proper technique is being employed and that the patient feels comfortable and stable.
B. The patient sits straight up on the edge of the bed.
Sitting straight up on the edge of the bed may not be suitable immediately after hip arthroplasty, especially with the posterior approach. The nurse should assess the patient's ability to sit upright without putting excessive pressure or strain on the surgical site.
C. The patient bends over the sink while brushing teeth.
Bending over can put stress on the surgical site and should be avoided during the initial recovery period after hip arthroplasty. This action might strain the incision and affect the healing process.
D. The patient leans over to pull on shoes and socks.
Similar to bending over the sink, leaning over to put on shoes and socks can strain the hip joint and surgical site. This movement could potentially put stress on the incision and hinder the healing process.
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