A nurse is teaching a client who has pneumonia about the use of an incentive spirometer. Which of the following instructions should the nurse Include?
"Tilt the spirometer toward yourself so you can see the balls rise."
"Inhale deeply and hold each breath for a minimum of 10 seconds."
"Exhale before sealing your lips around the mouthpiece."
"Use your incentive spirometer every 4 hours while you are awake."
The Correct Answer is D
A) "Tilt the spirometer toward yourself so you can see the balls rise": Tilting the spirometer is not necessary and may affect its accuracy. The spirometer should be held in an upright position to ensure correct measurement of inhalation.
B) "Inhale deeply and hold each breath for a minimum of 10 seconds": Inhaling deeply is important, but holding each breath for 10 seconds is not a typical recommendation for using an incentive spirometer. The goal is to inhale deeply and slowly, without necessarily holding the breath for an extended period.
C) "Exhale before sealing your lips around the mouthpiece": Exhaling before using the spirometer is not recommended. The correct procedure involves inhaling deeply and slowly after sealing your lips around the mouthpiece to ensure accurate measurement and effective lung expansion.
D) "Use your incentive spirometer every 4 hours while you are awake": Frequent use of the incentive spirometer, often every hour while awake, is recommended to improve lung function and prevent complications such as atelectasis. Using it every 4 hours may not be sufficient for effective respiratory therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Hiccups: Hiccups are not a common adverse effect of lisinopril. While they can be bothersome, they are not typically associated with this medication. Monitoring for more significant side effects is crucial, but hiccups alone are not usually indicative of a serious reaction.
B) Anxiousness: Anxiousness or anxiety is not a typical side effect of lisinopril. While anxiety can occur due to various factors, it is not directly linked to the use of lisinopril. The focus should be on more specific adverse effects related to the medication.
C) Cough: A persistent, dry cough is a well-documented adverse effect of lisinopril. Angiotensin-converting enzyme (ACE) inhibitors like lisinopril can cause a cough due to the accumulation of bradykinin. This side effect is significant and often leads to discontinuation of the medication.
D) Rhinorrhea: Rhinorrhea, or a runny nose, is not a common adverse effect of lisinopril. Although it can occur with other conditions or medications, it is not specifically associated with ACE inhibitors. Monitoring for more characteristic side effects of lisinopril is important.
Correct Answer is A
Explanation
A) Request return instructions in the client's own words:
Asking the client to repeat instructions in their own words is an effective strategy for ensuring understanding, especially for individuals with low health literacy. This technique, known as the "teach-back" method, allows the nurse to assess the client’s comprehension and clarify any misunderstandings.
B) Provide brochures that reflect a seventh-grade reading level:
While providing materials at a lower reading level can be helpful, it may not be sufficient for individuals with very low health literacy. It is essential to use multiple strategies, including verbal communication and interactive methods, to ensure understanding.
C) Limit teaching materials to written information:
Relying solely on written information is not advisable for clients with low health literacy. Visual aids, demonstrations, and verbal explanations should be included to enhance comprehension and retention of information.
D) Avoid repetition of information within each session:
Repetition is actually beneficial for clients with low health literacy. Repeating key information helps reinforce learning and ensures that the client retains the essential points discussed during the teaching sessions.
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