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 C
Explanation
Choice A rationale:
Procure platelet products from the blood bank. Rationale: Procuring platelet products from the blood bank is a specialized task that requires specific training and authorization. It should be performed by licensed healthcare providers, such as nurses or physicians, rather than unlicensed assistive personnel (UAP).
Choice B rationale:
Titrate oxygen to the prescribed parameters. Rationale: Titrating oxygen to prescribed parameters requires clinical judgment and assessment skills, which are beyond the scope of practice for UAP. This task should be performed by licensed nurses or respiratory therapists.
Choice C rationale:
Monitor an intravenous infusion rate on an established schedule. Rationale: This is the correct answer. UAP can be trained to monitor intravenous (IV) infusion rates on an established schedule for clients who do not require complex adjustments. It is within their scope of practice to ensure that the IV is running at the prescribed rate and to report any abnormalities or concerns to the nursing staff.
Choice D rationale:
Insert a urinary catheter for an uncomplicated client. Rationale: Inserting a urinary catheter is a specialized nursing procedure that should only be performed by licensed nurses or healthcare providers. It is not within the scope of practice for UAP, even for uncomplicated cases.
Correct Answer is A
Explanation
The correct answer and explanation is:
a) Health care proxy documentation.
This is the information that the PN should collect during the admission assessment of a terminally ill client to an acute care facility. Health care proxy documentation is a legal document that appoints a person to make health care decisions for the client when they are unable to do so themselves. It is important to have this information in case the client's condition deteriorates and they need end-of-life care.
b) Name of funeral home to contact.
This is not the information that the PN should collect during the admission assessment of a terminally ill client to an acute care facility. Name of funeral home to contact is a personal preference that may or may not be relevant for the client at this point. It is not a priority for the admission assessment, and it may be insensitive or inappropriate to ask the client about it.
c) Client's wishes regarding organ donation.
This is not the information that the PN should collect during the admission assessment of a terminally ill client to an acute care facility. Client's wishes regarding organ donation are a personal choice that may or may not be applicable for the client depending on their diagnosis, prognosis, and eligibility. It is not a priority for the admission assessment, and it may be offensive or upsetting to ask the client about it.
d) Contact information for the client's next of kin.
This is not the information that the PN should collect during the admission assessment of a terminally ill client to an acute care facility. Contact information for the client's next of kin is a general demographic data that may or may not be relevant for the client's care. It is not a priority for the admission assessment, and it may be already available in the client's records.
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