A nurse is providing education to a client who has a prescription for incentive spirometry. Which of the following instructions should the nurse include in the teaching?
"Use the incentive spirometer every 4 hours."
"Avoid coughing during and after the session."
"Remove the mouthpiece and exhale quickly."
"Place the mouthpiece in your mouth and inhale slowly."
The Correct Answer is D
A. "Use the incentive spirometer every 4 hours.": Incentive spirometry is typically recommended every 1 to 2 hours while awake to promote lung expansion and prevent atelectasis. Less frequent use may not provide adequate lung re-expansion, especially after surgery.
B. "Avoid coughing during and after the session.": Coughing is encouraged after using an incentive spirometer to help clear secretions and prevent respiratory complications such as pneumonia. Suppressing a cough can lead to mucus retention and increased risk of infection.
C. "Remove the mouthpiece and exhale quickly.": The client should exhale normally before using the spirometer, then inhale slowly through the mouthpiece to maximize lung expansion. Rapid exhalation does not promote adequate alveolar inflation.
D. "Place the mouthpiece in your mouth and inhale slowly.": Slow, deep inhalation through the spirometer allows for maximum lung expansion, reducing the risk of atelectasis. The client should maintain a steady breath to ensure optimal lung inflation and hold it for a few seconds before exhaling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Xerostomia: Radiation therapy to the head and neck often damages the salivary glands, leading to xerostomia, or dry mouth. This can cause difficulty in speaking, swallowing, and an increased risk of oral infections. Providing oral hydration and saliva substitutes can help manage this side effect.
B. Epistaxis: While radiation therapy can cause mucosal irritation, epistaxis (nosebleeds) is not a common side effect. Epistaxis is more frequently associated with conditions such as nasal trauma, clotting disorders, or chemotherapy-induced thrombocytopenia rather than localized radiation therapy.
C. Tinnitus: Radiation therapy does not typically cause tinnitus, which is more commonly linked to ototoxic medications, prolonged noise exposure, or inner ear disorders. If a tumor or treatment affects the auditory structures, hearing-related symptoms may occur but are not a primary radiation side effect.
D. Diplopia: Double vision is not a usual complication of radiation therapy to the head and neck. Diplopia is more commonly associated with neurological conditions, cranial nerve dysfunction, or ocular disorders rather than radiation-induced effects on surrounding tissues.
Correct Answer is B
Explanation
A. 1:1 ratio of P to QRS waves: Atrial fibrillation is characterized by chaotic atrial electrical activity, leading to the absence of distinct P waves. A 1:1 ratio of P to QRS waves is seen in normal sinus rhythm, not atrial fibrillation.
B. Absence of P waves: Atrial fibrillation causes rapid, disorganized atrial depolarization, resulting in the loss of identifiable P waves on ECG. Instead, fibrillatory waves are seen, and the ventricular response is irregularly irregular.
C. Prolonged PR interval: The PR interval represents the time between atrial and ventricular depolarization. In atrial fibrillation, there is no coordinated atrial depolarization, making the PR interval unmeasurable rather than prolonged.
D. Prolonged QT interval: A prolonged QT interval is associated with conditions like electrolyte imbalances, certain medications, and congenital syndromes, but it is not a typical feature of atrial fibrillation.
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