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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice d. Verify that Client B has two units of packed cells available.
Choice A rationale:
Moving Client D into an isolation room 24 hours before surgery is not necessary solely based on an elevated WBC count. Elevated WBCs indicate infection or inflammation, but isolation is not typically required unless there is a contagious infection.
Choice B rationale:
Client C’s potassium level of 3.8 mEq/L is within the normal range (3.5 to 5.0 mEq/L). Adding a banana, which is high in potassium, is not necessary.
Choice C rationale:
Client A with emphysema and an oxygen saturation of 94% does not require an increase in oxygen. Oxygen therapy should be carefully managed in clients with emphysema to avoid suppressing their respiratory drive.
Choice D rationale:
Client B has a postoperative hemoglobin of 8.2 mg/dL, which is significantly below the normal range (14 to 18 g/dL). This client may require a blood transfusion to address the low hemoglobin level, making it essential to verify the availability of packed red blood cells.
Correct Answer is C
Explanation
The correct answer is c. Recommend using a breast shield.
Choice A reason: Offering supplemental formula feedings is not the first-line action for inverted nipples as it does not address the issue and may lead to nipple confusion, potentially complicating future breastfeeding attempts.
Choice B reason: Teaching about the use of a breast pump is beneficial for milk expression but does not directly assist with the immediate concern of latching issues due to inverted nipples.
Choice C reason: Using a breast shield can be helpful for mothers with inverted nipples. It can temporarily draw out the nipple, allowing the baby to latch on more easily. This tool acts as a bridge between the breast and the baby's mouth, facilitating breastfeeding while the mother works on long-term solutions for her inverted nipples.
Choice D reason: Encouraging the use of ice on the areola may temporarily stiffen the nipple, but it is not a recommended practice for addressing inverted nipples as it can cause discomfort and may not be effective in promoting a successful latch.
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