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 D

Explanation

The correct answer is Choice D.

Choice A rationale: Depression assessment is important in bariatric care, but postoperative priorities focus on physiologic risks—venous thromboembolism, pulmonary complications, bleeding, and leaks—heightened by obesity, diabetes, hypertension, and immobility; psychosocial screening is longitudinal.

Choice B rationale: Urinary incontinence is not a typical complication of gastroplasty. Immediate risks include venous thromboembolism, pulmonary issues, hemorrhage, anastomotic leak, and infection; prioritizing VTE prophylaxis and respiratory support offers morbidity reduction.

Choice C rationale: Early post-gastroplasty nutrition requires staged progression: clear liquids to pureed, tiny portions, high-protein focus, vitamin-mineral supplementation. Offering meal variety risks overeating, nausea, vomiting, dumping syndrome, and staple-line stress or disruption.

Choice D rationale: Sequential compression devices augment venous return, reduce stasis, and lower deep vein thrombosis and pulmonary embolism risk in obese, diabetic, hypertensive surgical patients with limited mobility; evidence-based venous thromboembolism prophylaxis.

A. Increase the supplemental oxygen to 15 L/min via nasal cannula. B. Notify the health care provider of the client’s condition. C. Administer ibuprofen as ordered for fever. D. Obtain a sputum culture from the client. E. None F. None

Correct Answer is B

Explanation

Choice A rationale:

Increasing the supplemental oxygen to 15 L/min via nasal cannula may seem like a logical step given the client’s low oxygen saturation. However, it’s important to note that oxygen therapy should be titrated carefully. Too much oxygen can lead to oxygen toxicity, which can cause cellular damage and worsen the client’s condition. Therefore, this is not the priority action.

Choice B rationale:

Notifying the health care provider of the client’s condition is the priority action. The client’s oxygen saturation is 88% on room air, which is below the normal range of 95% to 100%. This indicates that the client is not getting enough oxygen, which can lead to hypoxia and other serious complications. The health care provider needs to be informed immediately so that appropriate interventions can be initiated.

Choice C rationale:

Administering ibuprofen as ordered for fever is important, but it’s not the priority in this situation. While fever can indicate an infection, which could be contributing to the client’s low oxygen saturation, addressing the immediate issue of hypoxia is more critical.

Choice D rationale:

Obtaining a sputum culture from the client could provide valuable information about the type of bacteria causing the pneumonia and guide antibiotic therapy. However, this is not an immediate priority compared to addressing the client’s low oxygen saturation. In summary, while all these actions are important in caring for a client with pneumonia, the nurse must prioritize interventions based on their urgency and potential impact on the client’s health status. In this case, notifying the health care provider of the client’s condition is the most critical action.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

Patient Data. Exhibits The nurse notes that the client’s oxygen saturation is 88% on room air. What is the priority action by the nurse?

Correct Answer is B

Explanation

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