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

Choice A rationale:

Obtaining a urine specimen for analysis is an important step in the assessment of the client with renal calculi. However, it is not the most immediate intervention when the client is experiencing severe flank pain and hematuria. Pain management should take precedence.

Choice B rationale:

This is the correct answer. Severe flank pain in a client with renal calculi is indicative of renal colic, which is typically excruciating. Administering a prescribed opioid analgesic is the priority to relieve the client's pain and distress.

Choice C rationale:

Straining the urine for the presence of stones is an essential nursing intervention to identify and collect any passed stones. However, it is not the most immediate action when the client is in severe pain. Pain management is the priority.

Choice D rationale:

Preparing the client for a prescribed computed tomography (CT) scan is an important diagnostic step to assess the location and size of the renal calculi. However, it is not the most immediate intervention when the client is in severe pain and distress. Pain management should come first.

A. Report the finding to the healthcare provider. B. Document the purposeful response to pain. C. Initiate seizure precautions immediately. D. Administer a prescribed PRN analgesic.

Correct Answer is A

Explanation

The correct answer is **a. Report the finding to the healthcare provider.**

Choice A rationale:

The nurse should report the finding of the client's response to a painful stimulus to the healthcare provider. This response, known as a decorticate posturing, is an abnormal motor response that indicates a severe brain injury or dysfunction. It is a sign of impaired consciousness and requires immediate medical attention and intervention.

Choice B rationale:

While documenting the client's response to pain is important, the primary action the nurse should take is to report the finding to the healthcare provider. Decorticate posturing is a neurological emergency that requires prompt medical evaluation and treatment.

Choice C rationale:

Initiating seizure precautions is not the appropriate action in this case. Decorticate posturing is not a seizure, but rather an abnormal motor response indicating a severe brain injury or dysfunction. Seizure precautions would not be the appropriate intervention.

Choice D rationale:

Administering a prescribed PRN analgesic is not the appropriate action in this case. Decorticate posturing is a neurological emergency that requires immediate medical attention, not just pain management. Administering an analgesic would not address the underlying neurological issue.

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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 with renal calculi is experiencing hematuria and reports severe flank pain.Which intervention should the nurse implement first?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

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Patient Data. Exhibits Which order would the nurse question? Select all that apply.

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