A nurse is teaching a client who has asthma about how to use a metered-dose inhaler with a spacer. Which of the following information should the nurse include in the teaching?

"Clean the spacer daily with cold water."

"Hold your breath for 10 seconds once you inhale."

"Wait 30 seconds between puffs."

"The spacer should make a whistling sound as you inhale."

Answer and Explanation

The Correct Answer is B

A) "Clean the spacer daily with cold water": While it is important to clean the spacer regularly to prevent bacterial growth, the recommendation is usually to clean it weekly with warm, soapy water rather than daily with cold water. This detail is essential for effective use but not the most critical point during initial teaching.

B) "Hold your breath for 10 seconds once you inhale": This statement is key to ensuring effective medication delivery. Holding the breath for about 10 seconds allows the medication to settle in the lungs, maximizing its therapeutic effects. This information is crucial for the client to understand the proper technique for using the inhaler with a spacer.

C) "Wait 30 seconds between puffs": While it is advisable to wait for a brief period between puffs to allow the first dose to be effective, the recommended wait time is generally around 1 minute, particularly if using a different medication or if instructed by the healthcare provider. Therefore, stating 30 seconds may be misleading.

D) "The spacer should make a whistling sound as you inhale": A whistling sound during inhalation may indicate that the spacer is being used incorrectly or that the client is inhaling too forcefully. The absence of a whistling sound is often a sign of proper technique. Therefore, this statement is misleading and not appropriate teaching for effective inhaler use.

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Correct Answer is D

Explanation

A) Serosanguineous drainage: While serosanguineous drainage can be expected after surgery, it is typically not alarming unless it significantly increases or changes in character. This finding alone does not indicate an immediate complication that requires urgent attention, making it a lower priority to report compared to other findings.

B) Client report of incisional pain: Postoperative pain is common and expected after a complete thyroidectomy. While the nurse should assess and manage the pain appropriately, this symptom is not unusual and does not signal a critical issue that would necessitate immediate reporting to the healthcare provider.

C) Client report of nausea: Nausea can occur after surgery due to anesthesia or medications. Although it should be addressed and managed, it is not a life-threatening complication. Therefore, this finding does not take priority over other more concerning symptoms.

D) Muscle twitching: Muscle twitching in a postoperative thyroidectomy patient may indicate hypocalcemia, a possible complication due to potential damage to the parathyroid glands during surgery. This condition can lead to severe complications if not addressed promptly, including tetany or seizures. Given the potential seriousness of this finding, it is critical for the nurse to report it to the healthcare provider immediately to ensure appropriate evaluation and intervention.

A. NG tube B. Wrist restraints C. Oral airway D. Tongue blade

Correct Answer is C

Explanation

A) NG tube: A nasogastric (NG) tube is not typically required for a client with a seizure
disorder unless there are specific feeding or medication administration needs post-seizure. It is not standard equipment for seizure management.

B) Wrist restraints: While restraints may be used in some situations to prevent injury, they are not routinely placed in a seizure patient's room and could increase the risk of harm during a seizure. It is generally best to ensure a safe environment without restraints.

C) Oral airway: Having an oral airway available in the client's room is essential for managing airway patency during or after a seizure. It can help to maintain an open airway, especially if the client becomes unresponsive or is at risk of aspiration.

D) Tongue blade: Using a tongue blade to hold the mouth open during a seizure is not recommended, as it can cause injury to the client or the nurse. It's a common myth that it should be used to prevent biting the tongue, but doing so can lead to more harm than good.

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A nurse is teaching a client who has asthma about how to use a metered-dose inhaler with a spacer. Which of the following information should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative following a complete thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider?

Correct Answer is D

Explanation

A nurse is planning care for a client who has a seizure disorder. Which of the following equipment should the nurse place in the client's room?

Correct Answer is C

Explanation

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