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 C
Explanation
A. A heart rate of 120 beats/minute in a 2-month-old infant is within the expected normal range, so there is no immediate need to alert the charge nurse. Routine findings should be documented and managed according to standard protocol.
B. Digoxin should be withheld in infants if the apical heart rate is below 90–110 beats/minute depending on age. Since the infant’s heart rate is within the normal range, withholding the medication is not indicated.
C. Digoxin can be safely administered because a heart rate of 120 beats/minute is appropriate for a 2-month-old infant. Documenting the heart rate ensures accurate recording of the assessment prior to administration and supports safe medication practice.
D. There is no indication to delay or recheck the heart rate in 1 hour because the current rate is within normal limits. Delaying medication could interfere with therapeutic management.
Correct Answer is C
Explanation
A callus is a normal response of the body during bone healing, where new bone tissue forms around the fracture site to provide stability and support. It helps in the process of bridging the fracture and promoting healing.
The PN can provide reassurance to the client by explaining that the presence of a callus indicates that the bone is healing and progressing toward recovery. It is important to educate the client about the expected timeline for bone healing and the need for continued follow-up with the healthcare provider.
Incorrect:
A. Prepare to assist in applying a new cast to reduce pressure points: This choice assumes that the client's concern is related to discomfort or pressure points caused by the current cast.
However, the client's concern is about the formation of a callus, which is a normal part of bone healing. There is no indication that a new cast is necessary at this point.
B. Report the client's concern to the healthcare provider: While it's important to address client concerns and communicate any changes in their condition to the healthcare provider, in this case, the formation of a callus is an expected part of the bone healing process. It is not necessary to report this concern to the healthcare provider as it is a normal occurrence.
D. Teach the client strategies to prevent further calluses: The formation of a callus in this context is a natural response of the body to promote bone healing. It is not necessary to teach the client strategies to prevent further calluses, as callus formation is a temporary and beneficial part of the healing process.
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