The unlicensed assistive personnel (UAP) who is caring for a postoperative client reports to the charge nurse that the client is not using the incentive spirometer effectively. What action should the charge nurse implement?

Encourage the UAP to demonstrate the effective use of the incentive spirometer to the client.

Schedule time later in the morning to review the use of the incentive spirometer with the client.

Ask the practical nurse assigned to care for the client to review the use of the spirometer with the client.

Advise the UAP that the respiratory therapist is responsible to supervise the client's use of the spirometer.

Answer and Explanation

The Correct Answer is C

A. Encouraging the UAP to demonstrate the effective use of the incentive spirometer may not be appropriate since the UAP may not have the necessary training or expertise to provide proper instruction.
B. Scheduling time later to review the use of the spirometer does not address the immediate need for the client to understand how to use it effectively and may delay important interventions for respiratory health.
C. Asking the practical nurse assigned to care for the client to review the use of the spirometer ensures that the client receives accurate and professional guidance. The practical nurse has the training to properly instruct the client on the effective use of the incentive spirometer, which is crucial for preventing complications like atelectasis.
D. Advising the UAP that the respiratory therapist is responsible for supervising the client's use of the spirometer does not empower the UAP to take action and does not address the immediate concern regarding the client’s ineffective use.

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Correct Answer is D

Explanation

Choice A: Checking mental acuity is important for assessing the client's cognitive function, but it may not be the most crucial intervention in the context of left- sided heart failure.

Choice B: Measuring urinary output is a valuable assessment in clients with heart failure, but it is not the most important intervention among the choices provided.

Choice C: Inspecting for sacral edema is a relevant assessment for clients with heart failure, especially when assessing for fluid retention. However, it may not be the highest priority in this case.

Choice D: Auscultating all lung fields is the most important intervention for a client with left-sided heart failure. Left-sided heart failure often results in pulmonary congestion, and auscultating the lung fields can provide critical information about the presence of crackles, wheezes, or other abnormal breath sounds, indicating worsening heart failure.

A. Refer the client to a dietitian for nutrition education. B. Provide pamphlets about heart-healthy diet selections. C. Suggest exercise as an alternative to increase HDL levels. D. Discuss client's concerns about the change in diet.

Correct Answer is D

Explanation

Choice A rationale: Referring the client to a dietitian for nutrition education is a proactive step. Dietitians can provide personalized guidance and address the client's dietary concerns and preferences. However, this alone may not be sufficient if the client is strongly resistant to dietary changes.

Choice B rationale: Providing pamphlets about heart-healthy diet selections is informative but may not effectively address the client's resistance to dietary changes. The client's reluctance needs to be explored and addressed through a more interactive approach.

Choice C rationale: While exercise is important for heart health, the primary concern here is the client's elevated cholesterol levels, which are significantly impacted by dietary choices. Suggesting exercise alone may not adequately address the issue at hand.

Choice D rationale: Discussing the client's concerns about the change in diet is the most appropriate initial action. It allows the nurse to understand the client's perspective, identify barriers to compliance, and work collaboratively with the client to develop a plan that considers his preferences and challenges. This approach is more likely to lead to a successful change in diet and lifestyle compared to simply providing information or referrals.

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The unlicensed assistive personnel (UAP) who is caring for a postoperative client reports to the charge nurse that the client is not using the incentive spirometer effectively. What action should the charge nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is assessing an older client with left-sided heart failure (HF). What intervention is most important for the PN to implement?

Correct Answer is D

Explanation

Correct Answer is D

Explanation

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The nurse is reviewing a nutrition plan with a client newly diagnosed with hypertension. Which statement by the client indicates an understanding of the Dietary Approaches to Stop Hypertension (DASH) diet?

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