The nurse is evaluating the effectiveness of the incentive spirometer implemented in the client's plan of care. Which outcome statement best describes the effectiveness of the incentive spirometer?
Client's breath sounds are clear to auscultation bilaterally.
Client exhibits a frequent productive cough.
Client demonstrates proper use of an incentive spirometer.
Client reports using the incentive spirometer every hour while awake.
The Correct Answer is A
A. Clear breath sounds indicate effective ventilation and oxygenation, which are the desired outcomes of incentive spirometry. This outcome directly reflects the effectiveness of the incentive spirometer in preventing atelectasis and improving lung expansion.
B. A productive cough suggests mobilization of secretions. While this is important for airway clearance, it is not a direct measure of the effectiveness of the incentive spirometer. This outcome is related to airway clearance, but not specifically to the incentive spirometer's role in lung expansion.
C. This outcome measures the client's ability to use the device correctly but does not assess the effectiveness of the device in improving lung function. This outcome is important but does not directly address the goal of the incentive spirometer.
D. This outcome measures compliance with the therapy but does not assess its effectiveness in improving lung function. This outcome is important for adherence but does not directly address the goal of the incentive spirometer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Clear breath sounds indicate effective ventilation and oxygenation, which are the desired outcomes of incentive spirometry. This outcome directly reflects the effectiveness of the incentive spirometer in preventing atelectasis and improving lung expansion.
B. A productive cough suggests mobilization of secretions. While this is important for airway clearance, it is not a direct measure of the effectiveness of the incentive spirometer. This outcome is related to airway clearance, but not specifically to the incentive spirometer's role in lung expansion.
C. This outcome measures the client's ability to use the device correctly but does not assess the effectiveness of the device in improving lung function. This outcome is important but does not directly address the goal of the incentive spirometer.
D. This outcome measures compliance with the therapy but does not assess its effectiveness in improving lung function. This outcome is important for adherence but does not directly address the goal of the incentive spirometer.
Correct Answer is A
Explanation
A. Vital signs are critical for assessing the client’s current hemodynamic status. Coffee-ground emesis can indicate gastrointestinal bleeding, which might lead to complications like hypovolemia or shock.
Vital signs can provide essential information about the client’s condition and help determine the urgency of intervention. Checking vital signs is a priority in assessing the severity of the situation and guiding further actions.
B. Measuring abdominal girth is useful in assessing for abdominal distention or fluid accumulation, which can be relevant in some gastrointestinal conditions. However, in the immediate context of coffee- ground emesis, the most urgent concern is evaluating the client's hemodynamic stability rather than focusing on abdominal girth.
C. Flushing of the skin might be relevant in certain contexts (e.g., reactions to medications or infections), but it is not directly related to the immediate concern of gastrointestinal bleeding and the client’s hemodynamic status. It is less critical compared to assessing vital signs in this situation.
D. While auscultating breath sounds is important for evaluating respiratory status and detecting any pulmonary complications, it is not the immediate priority in the context of coffee-ground emesis. The primary concern should be assessing for signs of hemodynamic instability that may result from gastrointestinal bleeding.
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