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 A
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Metoprolol 50 mg PO daily:
This is a beta-blocker that helps lower blood pressure and heart rate. While it may be part of managing heart failure, it is not the immediate priority in a client presenting with signs of fluid overload and congestion.
B. Maintain accurate intake and output records:
Monitoring intake and output is important in managing fluid balance.
However, in this situation, the priority is to address the existing fluid overload promptly.
C. Furosemide (Lasix) 40 mg push:
Furosemide is a loop diuretic that promotes the excretion of excess fluid. Administering it "push" implies a more rapid onset of action, making it suitable for addressing acute fluid overload.
D. Encourage fluid intake, more than 2000 mL/day:
In the context of fluid overload, encouraging additional fluid intake is contraindicated. The focus should be on removing excess fluid with diuretic therapy rather than promoting more intake.
Correct Answer is A
Explanation
A. Reposition the client every 2hr:
Regular repositioning helps redistribute pressure and prevent tissue damage. Turning the client every 2 hours is even better, especially for those at higher risk.
B. Elevate the head of the client's bed 45°:
Elevating the head of the bed can reduce pressure on the sacral area, which is a common site for pressure injuries. However, this alone is not sufficient, and regular repositioning should still be implemented.
C. Massage the client's bony prominences:
Massaging bony prominences can cause friction and shear, potentially increasing the risk of skin breakdown. This action is generally not recommended.
D. Provide the client with a high-calorie diet:
While proper nutrition is important for overall health, a high-calorie diet alone may not directly prevent pressure injuries. Adequate protein intake is particularly crucial for tissue repair and skin integrity.
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