The nurse instructs the client on the use of an incentive spirometer. Which observation indicates to the nurse that additional teaching is required?

Inhales through the mouthpiece.

Holds the mouthpiece with one hand.

Takes a deep breath through the nose.

Exhales after removing the mouthpiece.

Answer and Explanation

The Correct Answer is C

An incentive spirometer is used to help improve lung function by encouraging deep breathing. The user should inhale through the mouthpiece, not through the nose. This observation indicates that additional teaching is required.

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Correct Answer is ["A","C","F"]

Explanation

An increase in blood pressure (BP) from 112/68 mm Hg to 122/80 mm Hg indicates an improvement in hemodynamic status, as it shows that the client's blood vessels are constricting to maintain BP and tissue perfusion. f) An increase in urine output from 18 mL/hour to 45 mL/hour indicates an improvement in renal function and ﬂuid balance, which is important for maintaining hemodynamic stability. c) An increase in serum potassium level from 5 mEq/L (5 mmol/L) to 5.4 mEq/L (5.4 mmol/L) indicates an improvement in electrolyte balance, which is important for maintaining proper cardiac function and hemodynamic stability.

Option b) Serum sodium decreased from 146 mEq/L (146 mmol/L) to 138 mEq/L (138 mmol/L) is not a finding that indicates improvement in hemodynamic status. Hyponatremia or low serum sodium levels can cause ﬂuid shifts in the body leading to altered mental status, seizures, and cerebral edema, among other complications. However, the given information does not suggest that the client has hyponatremia or that their hyponatremia has improved.

Option d) Urine output averaging 18 mL/hour is not an improvement, and it may indicate renal insufficiency or failure, which can lead to ﬂuid overload and hemodynamic instability.

Option e) Bowel sounds in all four quadrants indicate normal bowel motility, which is important for proper digestion and absorption of nutrients but does not directly indicate an improvement in hemodynamic status.

A. Client demonstrates correct glucose testing. B. Client says 'I can do the testing now'. C. Client explains the testing process to the nurse. D. Client observes the nurse test glucose 5 times.

Correct Answer is A

Explanation

This is because the outcome of the plan is for the client to learn self-glucose testing, which implies that the client can perform the testing correctly on their own. Option A shows that the client has successfully learned and can perform the skill independently, which is the ultimate goal of the plan.

Option B, "Client says 'I can do the testing now'," and option C, "Client explains the testing process to the nurse," may show that the client has some understanding of the testing process, but they do not demonstrate that the client can perform the skill independently.

Option D, "Client observes the nurse test glucose 5 times," is not an appropriate method for evaluating the client's ability to perform self-glucose testing. Observing the nurse perform the skill does not demonstrate that the client has learned the skill themselves.

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The nurse instructs the client on the use of an incentive spirometer. Which observation indicates to the nurse that additional teaching is required?

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","C","F"]

Explanation

The nurse evaluates a client's plan of care. The client has an outcome of 'Client will learn self-glucose testing before discharge'. When evidence best allows the nurse to meet the outcome of the plan?

Correct Answer is A

Explanation

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