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."

Answer and Explanation

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.

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Correct Answer is D

Explanation

A) Dyspepsia:
Dyspepsia, or indigestion, is a common symptom of peptic ulcer disease, causing discomfort in the upper abdomen. While it is uncomfortable and should be managed, it is not immediately life-threatening and does not require urgent intervention compared to other symptoms.

B) Nausea:
Nausea can be a distressing symptom associated with peptic ulcer disease, often resulting from irritation of the stomach lining. Although it can significantly impact the client’s well-being and appetite, it is not as critical as symptoms indicating active bleeding or more severe complications.

C) Hyperactive bowel sounds:
Hyperactive bowel sounds may be present in peptic ulcer disease due to increased gastrointestinal activity. This finding suggests heightened digestive activity but does not indicate an immediate life-threatening condition that would take precedence over signs of active bleeding.

D) Hematemesis:
Hematemesis, or vomiting blood, is a serious and potentially life-threatening symptom that indicates active gastrointestinal bleeding. This requires immediate medical attention to prevent significant blood loss, shock, and other complications. It is the priority finding because it poses the most immediate risk to the client’s health and stability.

A. Press down on the canister top. B. Attach the spacer. C. Shake the haler. D. Hold breath for 10 seconds. E. Place lips around the mouthpiece.

Correct Answer is B,C,E,A,D

Explanation

B. Attach the spacer.: Attaching the spacer first ensures that the inhaler is properly connected and ready for use.

C. Shake the inhaler.: Shaking the inhaler is essential to mix the medication thoroughly before use.

E. Place lips around the mouthpiece.: Placing the lips around the mouthpiece is done while the inhaler is ready to be activated.

A. Press down on the canister top.: Pressing the canister releases the medication into the spacer, which the client will then inhale.

D. Hold breath for 10 seconds.: Holding the breath allows the medication to be fully absorbed into the lungs.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has peptic ulcer disease. Which of the following findings should the nurse identify as the priority?

Correct Answer is D

Explanation

Correct Answer is B,C,E,A,D

Explanation

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