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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","B","D","E"]

Explanation

A. Perform suction with sterile supplies:Sterile technique is essential when suctioning a tracheostomy to prevent introducing pathogens into the lower airway. Sterile supplies and gloves help reduce the risk of infection in this direct airway access point.

B. Auscultate lungs for retained secretions:Before suctioning, the nurse should assess for signs that suctioning is needed, such as abnormal breath sounds (e.g., crackles, rhonchi) that indicate secretion buildup in the airways.

C. Don clean gloves and lift out catheter and connect to suction:Clean gloves are insufficient for the suctioning procedure. This is an invasive technique involving direct access to the lower airway, requiring sterile gloves and equipment to prevent infection.

D. Wash hands and open sterile suction kit:Hand hygiene is a fundamental part of infection control. Opening the sterile suction kit properly maintains the sterility of equipment needed for the procedure.

E. Inform the patient about the procedure:Providing a brief explanation prepares the patient, reduces anxiety, and promotes cooperation. Even if the patient is nonverbal, communication is part of professional and ethical nursing care.

A. Have the client lean over an over-the-bed table. B. Use the bell of the stethoscope held lightly against the chest C. Use the diaphragm of the stethoscope held firmly against the chest. D. Instruct the client to take deep, rapid breaths through their nose.

Correct Answer is C

Explanation

A. Have the client lean over an over-the-bed table:This position is sometimes used during posterior thoracic examination or for percussing lung fields, but it is not standard for routine chest auscultation. Most chest sounds can be assessed with the client sitting upright or lying down.

B. Use the bell of the stethoscope held lightly against the chest:The bell is best for detecting low-pitched sounds like some heart murmurs, not respiratory sounds. Lung sounds are higher-pitched and require use of the diaphragm for accurate auscultation.

C. Use the diaphragm of the stethoscope held firmly against the chest:This is the correct technique for auscultating lung sounds, which are typically high-pitched. Holding the diaphragm firmly ensures clear transmission of breath sounds such as crackles, wheezes, or rhonchi.

D. Instruct the client to take deep, rapid breaths through their nose:Deep breathing is appropriate during auscultation, but it should be done through the mouth. Breathing through the nose may reduce air entry and obscure abnormal sounds, making it harder to detect lung pathology.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is setting up the environment for tracheal suction on a newly postoperative tracheostomy patient. Which action(s) should the nurse perform? (Select 4 correct answers)

Correct Answer is ["A","B","D","E"]

Explanation

The nurse is auscultating the chest in an adult client. Which technique is correct?

Correct Answer is C

Explanation

he nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal chamber. Which is the most appropriate nursing action?

A patient who will begin oxygen therapy has a history of sinus disorders. This patient would benefit most from which oxygen setup?

Which statement is most important for the nurse to make when caring for an anxious patient with a new tracheostomy?

A client is prescribed warfarin for the prevention of venous thromboembolism (VTE) following a right knee replacement. What should the nurse have available for a warfarin overdose?

A nurse assesses a client who has a chest tube. For which manifestations should the nurse immediately intervene? (Select 2 manifestations that apply.)

The nurse is caring for a hospitalized client who is retaining carbon dioxide (CO2) because of respiratory disease. The nurse anticipates which physical response will initially occur?

A patient with TB who is in respiratory isolation must go to the x-ray department. Which action should the nurse take?

The nurse is caring for a 20-year-old patient who recently had a tonsillectomy. The patient is fully awake and frequently clears his throat, but denies experiencing any pain. What is the most important action for the nurse to take first?