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

The correct answer is choice b. Respiratory alkalosis.

Choice A rationale:

Metabolic alkalosis occurs when there is a loss of acid or an increase in bicarbonate in the body. This can be due to vomiting, diuretic use, or excessive bicarbonate intake. It is not typically associated with hyperventilation.

Choice B rationale:

Respiratory alkalosis is caused by hyperventilation, which leads to a decrease in carbon dioxide (CO2) levels in the blood. This condition is often triggered by anxiety, fear, pain, or fever, all of which are present in this adolescent.

Choice C rationale:

Metabolic acidosis occurs when there is an accumulation of acid or a loss of bicarbonate in the body. This can be due to conditions like diabetic ketoacidosis, renal failure, or severe diarrhea. It is not typically associated with hyperventilation.

Choice D rationale:

Respiratory acidosis occurs when there is an accumulation of CO2 in the blood due to hypoventilation or impaired lung function. This condition is not consistent with hyperventilation, which reduces CO2 levels.

A. Ask questions in a vague, non-specific format. B. Begin with questions that are less sensitive in nature. C. Get the most difficult questions over with first. D. Share personal values to put the client at ease.

Correct Answer is B

Explanation

Choice A rationale:

Asking questions in a vague, non-specific format is not the best approach for addressing intimate partner violence. This approach may confuse the client or make them feel uncomfortable, as they may not know what specific information the nurse is seeking. It is essential to use clear and direct communication when addressing sensitive issues like intimate partner violence.

Choice B rationale:

Beginning with questions that are less sensitive in nature is the preferred approach when interviewing a client about intimate partner violence. This allows the nurse to establish rapport and build trust with the client before delving into more sensitive topics. Starting with less sensitive questions can help the client feel more comfortable and willing to share information about their situation.

Choice C rationale:

Getting the most difficult questions over with first is not the best approach when addressing intimate partner violence. Starting with the most challenging questions may cause the client to become defensive or unwilling to cooperate. It is essential to build a therapeutic relationship before discussing sensitive topics to ensure the client's emotional safety and willingness to disclose information.

Choice D rationale:

Sharing personal values to put the client at ease is not an appropriate approach when addressing intimate partner violence. It can be perceived as unprofessional and may compromise the objectivity and neutrality of the nurse in providing care. The focus should be on the client's needs and concerns, not the nurse's personal beliefs.

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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

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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