A nurse is teaching a client who has pneumonia about the use of an incentive spirometer. Which of the following instructions should the nurse Include?

"Tilt the spirometer toward yourself so you can see the balls rise."

"Inhale deeply and hold each breath for a minimum of 10 seconds."

"Exhale before sealing your lips around the mouthpiece."

"Use your incentive spirometer every 4 hours while you are awake."

Answer and Explanation

The Correct Answer is D

A) "Tilt the spirometer toward yourself so you can see the balls rise": Tilting the spirometer is not necessary and may affect its accuracy. The spirometer should be held in an upright position to ensure correct measurement of inhalation.

B) "Inhale deeply and hold each breath for a minimum of 10 seconds": Inhaling deeply is important, but holding each breath for 10 seconds is not a typical recommendation for using an incentive spirometer. The goal is to inhale deeply and slowly, without necessarily holding the breath for an extended period.

C) "Exhale before sealing your lips around the mouthpiece": Exhaling before using the spirometer is not recommended. The correct procedure involves inhaling deeply and slowly after sealing your lips around the mouthpiece to ensure accurate measurement and effective lung expansion.

D) "Use your incentive spirometer every 4 hours while you are awake": Frequent use of the incentive spirometer, often every hour while awake, is recommended to improve lung function and prevent complications such as atelectasis. Using it every 4 hours may not be sufficient for effective respiratory therapy.

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Correct Answer is A

Explanation

A) Muscle twitching:
Muscle twitching, also known as tetany, is a common manifestation of hypocalcemia. Low calcium levels increase neuromuscular excitability, leading to symptoms such as muscle cramps, spasms, and twitching. This is a key clinical sign that helps in diagnosing hypocalcemia.
B) Bounding pulse:
A bounding pulse is not typically associated with hypocalcemia. Instead, it is more often seen in conditions such as fluid overload or hyperdynamic circulatory states, where there is increased cardiac output or vascular volume.
C) Hypertension:
Hypertension is not a common manifestation of hypocalcemia. Hypocalcemia is more likely to cause hypotension due to its effect on cardiac contractility and vascular tone, rather than causing high blood pressure.
D) Decreased bowel sounds:
Decreased bowel sounds are not commonly associated with hypocalcemia. Hypocalcemia affects neuromuscular function, but it typically causes increased gastrointestinal motility rather than decreased motility, which would lead to hyperactive bowel sounds rather than decreased ones.

A. Antimicrobial medication can decrease the severity of symptoms. B. Postherpetic nerve pain can occur in older adult clients. C. Lesions often occur inside the oral cavity of clients who have this infection. D. Cellulitis is a common manifestation in clients who have this infection.

Correct Answer is B

Explanation

A. Antimicrobial medication can decrease the severity of symptoms.: Antiviral medications, rather than antimicrobial ones, are used to reduce the severity and duration of herpes zoster (shingles). They work best when started within 72 hours of the rash appearing.

B. Postherpetic nerve pain can occur in older adult clients.: Postherpetic neuralgia (PHN) is a common complication of herpes zoster, especially in older adults. It is characterized by persistent pain in the area where the shingles rash occurred.

C. Lesions often occur inside the oral cavity of clients who have this infection.: Herpes zoster typically causes a painful rash that appears on one side of the body, often in a band or strip, rather than inside the oral cavity. Oral lesions are more characteristic of herpes simplex virus infections.

D. Cellulitis is a common manifestation in clients who have this infection.: Cellulitis is not a typical manifestation of herpes zoster. Herpes zoster is characterized by a vesicular rash and pain along a dermatomal distribution, not by cellulitis.

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A nurse is teaching a client who has pneumonia about the use of an incentive spirometer. Which of the following instructions should the nurse Include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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