A postoperative client refuses to use an incentive spirometer following major abdominal surgery. What is the nurse’s priority action?

Determine the reasons why the client is refusing to use the incentive spirometer.

Document the client’s refusal to participate in health restorative activities.

Administer a pain medication to the client.

Answer and Explanation

The Correct Answer is A

The nurse’s priority action should be to determine the reasons why the client is refusing to use the incentive spirometer. Understanding the client’s concerns or fears can help the nurse address them and encourage the client to participate in this important aspect of postoperative care.

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Correct Answer is B

Explanation

Choice A rationale

This statement is incorrect. Advance directives do not allow the court to overrule an adult client’s refusal of medical treatment. They are legal documents that provide instructions for medical care and only go into effect if the individual cannot communicate their own wishes.

Choice B rationale

This statement is correct. Advance directives indicate the form of treatment a client is willing to accept in the event of a serious illness. They allow individuals to express their preferences about medical treatment at some point in the future, should they become unable to communicate their wishes.

Choice C rationale

This statement is incorrect. Advance directives do not permit a client to withhold medical information from health care personnel. They are used to communicate the individual’s wishes about medical treatment to their healthcare providers and family.

Choice D rationale

This statement is incorrect. Advance directives do not specifically allow health care personnel in the emergency department to stabilize a client’s condition. They are used to guide choices for doctors and caregivers if the individual is terminally ill, seriously injured, in a coma, in the late stages of dementia or near the end of life.

A. Inject 5 units of air into the bottle of regular insulin. B. Withdraw the correct dose of NPH insulin from the bottle. C. Inject 10 units of air into the bottle of NPH insulin. D. Withdraw the correct dose of regular insulin from the bottle.

Correct Answer is C,A,D,B

Explanation

Choice A rationale

Injecting 5 units of air into the bottle of regular insulin is the second step in the procedure. This is done after injecting air into the NPH insulin bottle. The purpose of this step is to pressurize the vial, making it easier to withdraw the insulin.

Choice B rationale

Withdrawing the correct dose of NPH insulin from the bottle is the last step in the procedure. This is done after withdrawing the regular insulin to prevent contamination of the regular insulin with the NPH insulin.

Choice C rationale

Injecting 10 units of air into the bottle of NPH insulin is the first step in the procedure. This is done before injecting air into the regular insulin bottle. The purpose of this step is to pressurize the vial, making it easier to withdraw the insulin.

Choice D rationale

Withdrawing the correct dose of regular insulin from the bottle is the third step in the procedure. This is done after injecting air into the regular insulin bottle and before withdrawing the NPH insulin. The purpose of this step is to ensure that the correct dose of regular insulin is administered.

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A postoperative client refuses to use an incentive spirometer following major abdominal surgery. What is the nurse’s priority action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make?

Correct Answer is B

Explanation

A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to be mixed together and administered subcutaneously. Determine the correct order of steps for this procedure.

Correct Answer is C,A,D,B

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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