The nurse observes a client using an incentive spirometer.
Which action should the nurse take?

Notify the healthcare provider that the client is having difficulty using the spirometer.

Encourage the client to continue to inhale slowly into the spirometer until the goal is met.

Offer to demonstrate the correct use of the incentive spirometer to the client.

Remind the client to cough after each use of the spirometer to help clear the lungs.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Notifying the healthcare provider that the client is having difficulty using the spirometer may be necessary if the client is unable to use the device correctly despite encouragement and education. However, the initial action should be to encourage the client and provide support.

Choice B rationale:

Encouraging the client to continue inhaling slowly into the spirometer until the goal is met is the correct action. Incentive spirometry is used to improve lung function, and it is essential for the client to use it correctly and meet their goals to achieve the desired outcomes.

Choice C rationale:

Offering to demonstrate the correct use of the incentive spirometer to the client may be helpful if the client is struggling to use it properly. However, the initial response should be to encourage the client and provide guidance.

Choice D rationale:

Reminding the client to cough after each use of the spirometer to help clear the lungs is not the most appropriate action in this situation. While coughing may be beneficial, the primary focus should be on achieving the goals of the incentive spirometry.

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Correct Answer is C

Explanation

Choice A rationale:

Administering protamine sulfate slowly intravenously within 30 minutes of heparin administration is not the recommended route and timing for reversing heparin's effects. Protamine sulfate is typically given slowly intravenously within 60 minutes of heparin administration.

Choice B rationale:

Administering protamine sulfate rapidly intramuscularly within 60 minutes of heparin administration is not the recommended route for this medication. Protamine sulfate should be given intravenously, not intramuscularly.

Choice C rationale:

Protamine sulfate should be given slowly intravenously within 60 minutes of heparin administration. This is the correct route and timing for reversing the anticoagulant effects of heparin.

Choice D rationale:

Administering protamine sulfate rapidly intramuscularly within 30 minutes of heparin administration is not the recommended route and timing for this medication. Intravenous administration is preferred for a more controlled and predictable reversal of heparin's effects.

A. Bring all medications, supplements, and herbs currently being taken to the next clinic appointment. B. Use a medication reminder system to prevent omitting to take the right medications at the right time. C. Make certain a family member knows the name and use of all medications currently being taken. D. Do not take any over-the-counter drugs while taking medications prescribed by a healthcare provider.

Correct Answer is A

Explanation

Choice A rationale:

Instructing the client to bring all medications, supplements, and herbs currently being taken to the next clinic appointment (Choice A) is the best course of action. This allows the healthcare provider to review the client's entire medication regimen, identify any potential interactions or duplications, and make appropriate adjustments. It promotes medication safety and ensures that the client receives the most effective and safe treatment.

Choice B rationale:

Using a medication reminder system (Choice B) is a helpful suggestion but does not address the issue of potential duplications or interactions between medications. While a reminder system can improve adherence, it does not provide a comprehensive solution to the problem of multiple prescriptions for the same indication.

Choice C rationale:

Making certain a family member knows the name and use of all medications currently being taken (Choice C) is a useful practice for medication safety but may not be sufficient to address the issue of multiple prescriptions. Relying solely on a family member's knowledge may lead to misunderstandings or omissions in the medication regimen.

Choice D rationale:

Do not take any over-the-counter drugs while taking medications prescribed by a healthcare provider (Choice D) is a relevant piece of advice for medication safety. However, it does not directly address the issue of multiple prescriptions for the same indication. It is essential for the client to have a complete and accurate record of all medications, both prescribed and over-the-counter, to ensure safe and effective treatment.

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The nurse observes a client using an incentive spirometer. Which action should the nurse take?

Nursing Test Bank

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Correct Answer is C

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The nurse observes a client using an incentive spirometer.
Which action should the nurse take?