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 D
Explanation
A. Report of decreased urinary output
Explanation: Decreased urinary output is not typically associated with hyperglycemia. In fact, increased urinary output (polyuria) is more characteristic.
B. Random blood glucose 126 mg/dL
Explanation: This level is within the normal range for random blood glucose. Hyperglycemia is usually defined by higher blood glucose levels.
C. Clammy skin
Explanation: Clammy skin is not a direct manifestation of hyperglycemia. Symptoms of hyperglycemia may include increased thirst, frequent urination, and blurred vision.
D. History of poor wound healing
Explanation: This is correct. Hyperglycemia can contribute to impaired wound healing, as it affects the body's ability to repair tissues.
Correct Answer is D
Explanation
A. Intact skin with localized erythema:
Explanation: This description is more consistent with a stage 1 pressure injury, where there is non-blanchable erythema.
B. Full thickness skin loss with visible bone:
Explanation: This description is more consistent with a stage 4 pressure injury, which involves extensive tissue loss, including exposure of bone.
C. Full thickness skin loss with visible adipose tissue:
Explanation: This finding is characteristic of a stage 3 pressure injury, where the loss of tissue extends down to the subcutaneous layer.
D. Partial-thickness skin loss with red tissue in the wound bed:
Explanation: This description is consistent with a stage 2 pressure injury, where there is partial-thickness skin loss involving the epidermis and possibly the dermis, forming a shallow open ulcer with a red-pink wound bed.
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