MA is a 85 year old female who is admited to the hospital with Pneumonia. Education has begun on proper breathing techniques to expand lung volume as much as possible and allow for proper oxygen blood exchange within the alveoli. Which device will help her achieve this as educated by the nurse?
4L of oxygen via Nasal Cannula
Fluter Valve
Incentive Spirometer
Abdominal Binder
The Correct Answer is C
An Incentive Spirometer is a device that helps patients take deep breaths and improve their lung function. It encourages patients to take deep breaths and to hold them for a few seconds. The device also helps to monitor and measure lung volume. By using an incentive spirometer, MA can expand her lung volume as much as possible and allow for proper oxygen blood exchange within the alveoli. This is an important technique to help prevent pneumonia and other respiratory complications.
The other options mentioned, 4L of oxygen via Nasal Cannula, Fluter Valve, and Abdominal Binder, are not appropriate devices to help MA achieve proper breathing techniques and expand lung volume. 4L of oxygen via Nasal Cannula is used to provide supplemental oxygen to patients who have difficulty breathing. Fluter Valve is a handheld device used for airway clearance in patients with chronic obstructive pulmonary disease (COPD) or cystic fibrosis. An abdominal binder is a wrap that is placed around the abdomen to support the abdominal muscles and help reduce pain after surgery or injury. These devices do not help improve lung function and are not appropriate for MA's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Fluid retention is a common complication in heart failure, and monitoring the client's fluid status is crucial to manage the condition effectively. Daily weights are an essential component of monitoring fluid status and are the most sensitive and practical method to detect changes in the client's fluid status. Weight gain is a reliable indicator of fluid retention, and even small increases in weight can indicate the need for changes in the client's treatment plan.
Although electrolyte monitoring (option a), output measurements (option c), and daily BUN and serum creatinine monitoring (option d) can provide valuable information about the client's fluid status, they are not as sensitive or practical as daily weights. Electrolyte monitoring can help detect changes in fluid balance, but it does not provide a direct indication of fluid status. Output measurements can indicate fluid loss, but they do not provide an accurate assessment of fluid retention. BUN and serum creatinine monitoring can detect changes in renal function, but they are not specific to fluid status.
Correct Answer is A
Explanation
Pulse oximetry is a non-invasive method of monitoring the oxygen saturation level in the blood. A normal range for oxygen saturation is between 95% and 100%. An oxygen saturation level of 89% indicates hypoxemia, which is a serious condition that can lead to tissue damage, organ failure, and even death if left untreated.
Therefore, the priority nursing action is to perform a respiratory assessment to determine the cause of the hypoxemia. This should include assessing the client's airway patency, breathing patern, lung sounds, and oxygen therapy if the client is already receiving it. The nurse should also observe for any signs of respiratory distress such as cyanosis, accessory muscle use, or difficulty breathing.
While it is important to document hypoxemia and report it to the healthcare provider, the priority at this time is to assess and intervene promptly to prevent further deterioration of the client's condition. Checking the placement of the pulse oximeter may be necessary if the reading is unreliable, but it is not the priority in this scenario.
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