A nurse is reinforcing client instructions on the use of an incentive spirometer. Which of the following statements made by the client indicates an understanding of the teaching?

“I will rest my hand over my abdomen to create resistance."

“I will lie on my back with my knees bent."

“I will place the adapter on my finger to read my blood oxygen saturation level."

"I will take in a deep breath and hold it before exhaling."

Answer and Explanation

The Correct Answer is D

A. “I will rest my hand over my abdomen to create resistance.” This technique is used for diaphragmatic breathing exercises, not incentive spirometry. It does not help assess or improve lung expansion, which is the primary goal of using the incentive spirometer.

B. “I will lie on my back with my knees bent.” While lying down may be appropriate for some breathing exercises, the incentive spirometer is best used in a sitting or upright position. Sitting allows for maximal lung expansion and facilitates more effective use of the device.

C. “I will place the adapter on my finger to read my blood oxygen saturation level.” This describes the use of a pulse oximeter, not an incentive spirometer. The spirometer measures inspiratory volume, while pulse oximetry is used to monitor oxygen saturation.

D. "I will take in a deep breath and hold it before exhaling." The client should inhale slowly and deeply through the mouthpiece, hold the breath for several seconds to promote alveolar inflation, then exhale. This process helps prevent atelectasis and promotes lung expansion.

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Correct Answer is A

Explanation

A. Obtain a throat culture:Attempting to visualize or culture the throat in a child with epiglottitis is dangerous and can trigger laryngospasm, leading to sudden airway obstruction. Any procedure that manipulates the airway should be avoided.

B. Administer humidified oxygen:Humidified oxygen helps ease breathing and reduce airway irritation. It is a supportive measure that can be safely administered without disturbing the airway and is commonly used in cases of respiratory distress such as epiglottitis.

C. Administer acetaminophen for fever:Fever is a common symptom of epiglottitis, and acetaminophen can be safely used to reduce temperature and increase comfort. It poses no risk to airway integrity and supports symptomatic relief.

D. Obtain axillary temperatures:Using the axillary route avoids disturbing the oral cavity, making it a safe and appropriate method for monitoring temperature in a child with suspected or confirmed epiglottitis. It minimizes the risk of triggering airway complications.

A. Placing infants on their backs or sides for sleep B. Positioning the infant prone for sleep C. Wrapping the infant snugly for rest periods D. Sitting the infant up in an infant seat

Correct Answer is A

Explanation

A. Placing infants on their backs or sides for sleep:The "Back to Sleep" campaign recommends placing infants on their backs for all sleep times to significantly reduce the risk of SIDS. Back sleeping it keeps the airway more open and reduces the chance of suffocation.

B. Positioning the infant prone for sleep:Placing an infant on their stomach increases the risk of SIDS due to potential airway obstruction and rebreathing of exhaled carbon dioxide. This position is strongly discouraged by pediatric guidelines for safe sleep.

C. Wrapping the infant snugly for rest periods:Swaddling can be safe if done correctly, but wrapping too tightly, especially around the chest or hips, and using loose blankets can increase the risk of overheating or suffocation.

D. Sitting the infant up in an infant seat:Keeping an infant in a sitting position for sleep, such as in a car seat or infant carrier, increases the risk of airway obstruction and is not recommended for routine sleep. Infants should sleep on a flat, firm surface to reduce the risk of SIDS.

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A nurse is reinforcing client instructions on the use of an incentive spirometer. Which of the following statements made by the client indicates an understanding of the teaching?

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