A client is using an incentive spirometer on the first postoperative day after an inguinal herniorrhaphy. The practical nurse (PN) should reteach the proper use of the spirometer when the client demonstrates which action.
Blowing forcefully into the mouthpiece.
Exhaling slowly after two seconds.
Using a tight seal around the mouthpiece.
Sitting upright during the treatment.
The Correct Answer is A
The practical nurse (PN) should reteach the proper use of the spirometer when the client demonstrates blowing forcefully into the mouthpiece. The proper way to use an incentive spirometer is to sit upright, hold the spirometer upright, place your mouth around the mouthpiece, breathe out slowly, and then inhale slowly only through your mouth as deeply as you can. Blowing forcefully into the mouthpiece is not the correct way to use an incentive spirometer.
B. Exhaling slowly after two seconds: This is actually a correct action when using an incentive spirometer. The proper way to use an incentive spirometer is to exhale slowly before inhaling deeply.
C. Using a tight seal around the mouthpiece: This is also a correct action when using an incentive spirometer. It’s important to create a tight seal around the mouthpiece with your lips to ensure that you’re inhaling and exhaling only through your mouth.
D. Sitting upright during the treatment: This is another correct action when using an incentive spirometer. Sitting upright helps you to breathe more deeply and fully, which is the goal of using an incentive spirometer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Hives (also known as urticaria) are raised, red, itchy welts on the skin that can be caused by an allergic reaction to medication, including antibiotics. It is essential for the PN to recognize this potentially severe allergic reaction and take immediate action.
Immediate action steps include:
- Stop the infusion of the intravenous antibiotic immediately.
- Notify the healthcare provider and report the allergic reaction.
- Assess the client's airway, breathing, and circulation to ensure there are no signs of respiratory distress or anaphylaxis.
- Administer prescribed emergency medications if needed (e.g., epinephrine, antihistamines).
- Monitor the client closely for any further signs of an allergic reaction or anaphylaxis.
The other assessment findings mentioned are also important to address, but they do not require immediate action:
A- Dry mouth with thirst: This may indicate dehydration, which should be addressed by encouraging the client to drink fluids, but it does not pose an immediate threat to the client's safety.
B- Warm skin with elastic turgor: This suggests that the client is adequately hydrated, and the skin's elasticity is normal, which is a positive finding.
C- Low-grade fever with diaphoresis: A low-grade fever indicates a mild elevation in temperature, and diaphoresis (sweating) may be the body's response to regulate temperature. The PN should monitor the client's temperature and assess for other signs of infection, but this finding does not require immediate action
Correct Answer is A
Explanation
A. Checking the medical record for the correct signed consent form is within the PN’s scope of practice. The PN ensures that proper documentation is completed before the procedure.
B. Explaining the examination and obtaining consent is the responsibility of the healthcare provider (e.g., physician or advanced practice nurse) performing the procedure. The PN does not obtain informed consent.
C. Obtaining consent from a family member is only appropriate if the client is legally unable to provide consent (e.g., unconscious or lacks decision-making capacity), and legal documentation is in place.
D. Asking if the client understands the exam is important, but the PN does not provide the detailed explanation required for informed consent. The provider must clarify any concerns.
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