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 C

Explanation

A. "I'll rinse my mouth after taking this medication."

Montelukast is taken orally and is not associated with the risk of oral thrush or other mouth-related side effects that would require rinsing the mouth after administration. This action is more commonly associated with inhaled corticosteroids, not leukotriene receptor antagonists.

B. "I'll use this medication when I get an asthma attack."

Montelukast is not a rescue medication for asthma attacks. It is a long-term controller medication used to manage and prevent asthma symptoms, not to treat acute attacks. Short-acting bronchodilators such as albuterol are used for quick relief during asthma attacks.

C. "I'll take this medication once a day in the evening."

Montelukast is a leukotriene receptor antagonist commonly used to manage asthma. It is typically taken orally once daily, usually in the evening, to provide 24-hour control of asthma symptoms and improve lung function. Therefore, the statement indicating an understanding of the teaching is option C.

D. "I'll decrease my sodium intake while I'm taking this medication."

Montelukast is not known to affect sodium levels in the body or require any specific dietary modifications, such as decreasing sodium intake. Therefore, this statement is unrelated to the use of montelukast for asthma management

A. Encourage fluid intake of 2.5 L per day. B. Assist the client to cough and deep breathe every 4 hr. C. Encourage independence in completing ADLs. D. Use an N-95 respirator when providing client care.

Correct Answer is A

Explanation

A. Encourage fluid intake of 2.5 L per day.

This is an appropriate intervention for a client with pneumonia. Increasing fluid intake helps to thin respiratory secretions, making them easier to cough up and clear from the airways. Adequate hydration also supports overall health and immune function. However, the nurse should consider the client's individual fluid tolerance and any comorbid conditions such as heart failure that may necessitate fluid restriction.

B. Assist the client to cough and deep breathe every 4 hr.

This intervention is also appropriate for a client with pneumonia. Coughing and deep breathing exercises help to mobilize and clear respiratory secretions, preventing complications such as atelectasis and pneumonia. However, the frequency of coughing and deep breathing may need to be tailored to the client's tolerance and respiratory status.

C. Encourage independence in completing ADLs.

While promoting independence in activities of daily living (ADLs) is generally beneficial for older adult clients, in the context of pneumonia, the priority is to ensure adequate rest and conserve energy for recovery. Depending on the severity of the illness, the client may experience fatigue and dyspnea, making it challenging to perform ADLs independently. The nurse should assess the client's functional status and provide assistance as needed while promoting independence to the extent possible.

D. Use an N-95 respirator when providing client care.

This intervention is not directly relevant to the care plan for a client with pneumonia. N-95 respirators are primarily used for respiratory protection against airborne infectious agents such as tuberculosis or certain viral infections like COVID-19. While standard precautions should be followed when caring for a client with pneumonia to prevent the spread of infection, including hand hygiene and appropriate use of personal protective equipment (PPE), an N-95 respirator is not typically indicated unless the client has a specific respiratory pathogen requiring airborne precautions.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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