A postoperative client refuses to use an incentive spirometer following major abdominal surgery. What is the nurse’s priority action?
Determine the reasons why the client is refusing to use the incentive spirometer.
Document the client’s refusal to participate in health restorative activities.
Administer a pain medication to the client.
The Correct Answer is A
The nurse’s priority action should be to determine the reasons why the client is refusing to use the incentive spirometer. Understanding the client’s concerns or fears can help the nurse address them and encourage the client to participate in this important aspect of postoperative care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Infiltration of an IV site is characterized by skin blanching, which is a whitening or lightening of the skin. This occurs when IV fluids or medications leak into the surrounding tissue from the vein. The area may also be cool to touch and swollen.
Correct Answer is B
Explanation
Choice A rationale: Using a resuscitation bag with 80% oxygen prior to the procedure is inappropriate. While pre-oxygenation is important before suctioning to prevent hypoxia, the oxygen concentration should be 100%, not 80%. Normal oxygen saturation levels are 95% to 100%. Pre-oxygenating with 100% oxygen ensures the patient maintains adequate oxygenation during the brief suctioning period. Using 80% oxygen does not fully optimize oxygen reserves for this purpose.
Choice B rationale: Selecting a suction catheter that is half the size of the tracheostomy lumen is appropriate. This size prevents excessive occlusion of the airway, ensuring adequate airflow during suctioning. The correct catheter size minimizes trauma to the tracheal mucosa and prevents hypoxia. The catheter should not exceed 50% of the tracheostomy diameter to maintain proper airway function, making this the correct action for safe and effective suctioning.
Choice C rationale
Placing the end of the suction catheter in water-soluble lubricant is not recommended. This could introduce bacteria into the airway and increase the risk of infection.
Choice D rationale
Adjusting the wall suction apparatus to a pressure of 170 mm Hg is not correct. The recommended suction pressure for adults is usually between 80 and 120 mm Hg. Suctioning at too high a pressure can cause trauma to the airway.
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