A nurse is reinforcing teaching with a client who is having difficulty using an incentive spirometer. Which of the following instructions should the nurse include in the teaching?

Start slowly and increase volume over several sessions.

Do regular deep-breathing exercises instead.

Use another device because this one is might be faulty.

Be much more vigorous in increasing increments.

Answer and Explanation

The Correct Answer is A

A. Start slowly and increase volume over several sessions.

This is the correct choice. For clients having difficulty using an incentive spirometer, starting slowly and gradually increasing the volume over several sessions is an appropriate approach. It allows the client to become familiar with the device and the technique required for effective use. Starting slowly also reduces the risk of discomfort or respiratory distress, allowing the client to build up their lung capacity gradually and achieve optimal results over time.

B. Do regular deep-breathing exercises instead.

Regular deep-breathing exercises are beneficial for improving lung function and respiratory strength. However, using an incentive spirometer serves a specific purpose in promoting deep breathing and lung expansion to prevent atelectasis (lung collapse) and improve respiratory function. While deep-breathing exercises are helpful, they may not provide the same targeted benefits as using an incentive spirometer, especially for clients who are experiencing difficulty with deep breathing or lung expansion.

C. Use another device because this one might be faulty.

This option assumes that the difficulty with the incentive spirometer is due to a fault in the device itself, which may not necessarily be the case. Before considering another device, it's important to ensure that the client is using the current device correctly and receiving proper instruction. If the client continues to have difficulty despite proper technique and instruction, then further assessment of the device may be warranted.

D. Be much more vigorous in increasing increments.

Being much more vigorous in increasing increments is not recommended, as it could lead to discomfort, respiratory distress, or hyperventilation for the client. Increasing the volume too quickly may overwhelm the client and make it more difficult for them to use the incentive spirometer effectively. Gradual progression allows the client to adjust to the device and build up their lung capacity safely and effectively over time.

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Correct Answer is A

Explanation

A. Assess the patient; check to see if the oxygen is flowing correctly:

This option involves assessing the patient's condition promptly, particularly focusing on the adequacy of oxygenation. Checking the oxygen delivery system ensures that the patient is receiving the prescribed oxygen therapy at the appropriate flow rate. In a patient with shortness of breath (SOB) and increasing confusion and combativeness, hypoxemia (low oxygen levels) could be a contributing factor. Therefore, assessing the oxygen delivery system is crucial to ensure proper oxygenation and address potential causes of the patient's symptoms.

B. Page the MD STAT:

Paging the MD STAT may be necessary after assessing the patient's condition, especially if the patient's symptoms indicate a medical emergency or require immediate intervention. However, in this scenario, the priority is to assess the patient's condition and address any immediate concerns related to oxygenation and respiratory status. While paging the healthcare provider may be necessary, it should not delay the initial assessment and interventions needed to stabilize the patient.

C. Put up the patient's side rails and apply soft restraints:

Applying side rails and soft restraints should not be the first action in response to the patient's symptoms. While patient safety is important, these measures should only be implemented after other interventions have been attempted, and there is a risk of harm to the patient or others due to agitation or combativeness. In this case, the patient's confusion and combativeness may be secondary to hypoxemia, so addressing oxygenation and assessing the patient's condition are the immediate priorities.

D. Administer an IM sedative:

Administering a sedative should not be the first action in this scenario. Sedation may be considered if the patient's agitation or combativeness poses a risk to their safety or interferes with assessment and treatment. However, the underlying cause of the patient's symptoms, such as hypoxemia, should be addressed first. Administering a sedative without addressing the potential cause of the patient's symptoms could mask important clinical indicators and delay appropriate treatment.

A. Air moves in and out of a wound in the chest wall. B. Air cannot pass freely into the thoracic cavity through a chest wound. C. There are no audible sounds in an open pneumothorax. D. The air is trapped when it enters the cavity.

Correct Answer is A

Explanation

A. Air moves in and out of a wound in the chest wall.

In an open pneumothorax, also known as a sucking chest wound, there is a communication between the pleural space and the external environment through a wound in the chest wall. This allows air to move freely in and out of the pleural cavity during respiration. As a result, there is a loss of negative pressure within the pleural space, impairing lung expansion and leading to respiratory compromise. This condition is considered a medical emergency and requires prompt intervention to prevent tension pneumothorax and respiratory failure.

B. Air cannot pass freely into the thoracic cavity through a chest wound.

In an open pneumothorax, air can pass freely into the thoracic cavity through the chest wound. This communication between the external environment and the pleural space results in air movement in and out of the wound during respiration.

C. There are no audible sounds in an open pneumothorax.

In an open pneumothorax, there may be audible sounds, such as sucking or hissing sounds, particularly during inspiration. These sounds occur due to the movement of air in and out of the chest wound and can be indicative of the condition.

D. The air is trapped when it enters the cavity.

In an open pneumothorax, the air is not trapped when it enters the pleural cavity. Instead, air moves freely in and out of the wound in the chest wall, leading to respiratory compromise and potential progression to tension pneumothorax if left untreated.

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A nurse is reinforcing teaching with a client who is having difficulty using an incentive spirometer. Which of the following instructions should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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