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 B

Explanation

Serum creatinine is the most important laboratory value to review before administering an antibiotic that can cause nephrotoxicity. Nephrotoxicity is an alteration in the function of the kidney due to exposure to certain drugs or toxins.

It can be assessed by measuring the glomerular filtration rate (GFR), which is the rate of clearance of a substance from the blood by the kidneys. Serum creatinine is a waste product of muscle metabolism that is freely filtered by the glomeruli and not reabsorbed or secreted by the tubules.

Therefore, it is a reliable indicator of GFR and renal function. An increase in serum creatinine indicates a decrease in GFR and renal function, which may be caused by nephrotoxic drugs.

The other laboratory values are not directly related to nephrotoxicity or GFR:

Serum calcium: This may be aﬀected by renal function, but it is not a sensitive or specific marker of nephrotoxicity. It may be altered by other factors such as vitamin D, parathyroid hormone, and bone metabolism.
Hemoglobin and hematocrit: These may be aﬀected by renal function, but they are not sensitive or specific markers of nephrotoxicity. They may reﬂect the erythropoietin production by the kidneys, which stimulates red blood cell production in the bone marrow. However, they may also be inﬂuenced by other factors such as blood loss, hydration status, and iron deficiency.
White blood cell count (WBC): This is not related to nephrotoxicity or GFR. It may reﬂect the presence of infection or inﬂammation, which may be a cause or a consequence of renal impairment, but it is not a direct measure of renal function.

A. Refer client to the social worker for support therapy. B. Encourage client to implement relaxation techniques. C. Leave the client's room and return later in the day. D. Explain that insulin is a life-saving drug for the client.

Correct Answer is C

Explanation

Choice A rationale:

Referring the client to a social worker for support therapy may be premature at this stage. The client's initial reaction may be due to fear or anxiety about the diagnosis and self-administration of insulin. Pushing the client into therapy without assessing their readiness may not be appropriate.

Choice B rationale:

Encouraging the client to implement relaxation techniques assumes that the client is open to learning and just needs help with anxiety management. However, the client's refusal to have the nurse in the room suggests that they are not currently receptive to teaching. It's important to address the client's emotional state first.

Choice C rationale:

Leaving the client's room and returning later in the day is the most appropriate initial action. The client's loud refusal indicates a need for privacy and emotional space. By respecting the client's wishes and revisiting the teaching later, the nurse can establish trust and build a better rapport.

Choice D rationale:

Explaining that insulin is a life-saving drug is informative but may not be effective in this situation, as the client has already requested the nurse to leave the room. Providing information about the importance of insulin should come after establishing a therapeutic nurse-client relationship.

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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

Before administering an antibiotic that can cause nephrotoxicity, which laboratory value is most important for the practical nurse (PN) to review?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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