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:

Nausea can be a significant factor contributing to decreased food intake, but it is not the most likely cause in this scenario. Xerostomia (dry mouth) and mucositis are mentioned as symptoms in the question stem. Nausea alone does not explain why the client is consuming less than their body requirements.

Choice B rationale:

Fatigue can also contribute to decreased food intake, but it is not the most likely cause in this case. While fatigue can be a side effect of cancer treatment and may lead to reduced appetite, the question specifically mentions xerostomia and mucositis as issues contributing to imbalanced nutritional intake.

Choice C rationale:

Pain when eating is the most likely cause of imbalanced nutritional intake in this scenario. The client's laryngeal cancer and the development of mucositis indicate that eating is likely painful for them. This discomfort can significantly deter the client from eating, leading to decreased nutritional intake.

Choice D rationale:

Altered taste sensation can affect food preferences, but it is not the most likely cause in this case. Pain when eating is a more direct and immediate barrier to food intake, especially in the context of mucositis and laryngeal cancer.

A. Serum blood glucose (BG) level. B. Neutrophil count. C. Serum albumin. D. Hematocrit.

Correct Answer is B

Explanation

Choice A rationale:
Serum blood glucose (BG) level is not directly related to the presence of purulent drainage at a burn wound site. Elevated BG levels might be seen in clients with diabetes or as a stress response, but they are not the primary indicator of infection or wound complications.
Choice C rationale:
Serum albumin levels can be relevant in assessing nutritional status and the body's ability to heal wounds. However, they do not directly indicate the presence of infection or purulent drainage. Low serum albumin levels may be seen in clients with malnutrition but do not provide immediate information about the wound.
Choice D rationale:
Hematocrit measures the percentage of red blood cells in the blood and is not directly related to the presence of purulent drainage at a burn wound site. Elevated hematocrit may indicate dehydration or hemoconcentration but does not specifically address the issue of wound infection.

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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

A client who is receiving radiation treatment for laryngeal cancer has developed xerostomia and mucositis.The nurse determines the client has an imbalanced nutritional intake and is consuming less than body requirements.Which factor is the most likely cause for this problem?

Correct Answer is C

Explanation

While caring for a client with a full-thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values.

Correct Answer is B

Explanation

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