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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale

Touching the patient’s face with a cotton ball is not part of the Romberg test. This action is more commonly associated with tests of facial sensation.

Choice B rationale

Applying a vibrating tuning fork to the patient’s forehead is not part of the Romberg test. This action is more commonly associated with tests of vibratory sensation.

Choice C rationale

Having the patient stand with their arms at their sides and their feet together is the correct method for conducting a Romberg test.

Choice D rationale

Performing direct percussion over the area of the kidneys is not part of the Romberg test. This action is more commonly associated with tests of kidney function or the presence of kidney disease.

A. Use a bed exit alarm system. B. Raise four side rails while the patient is in bed. C. Apply one soft wrist restraint. D. Dim the lights in the patient’s room.

Correct Answer is A

Explanation

Choice A rationale

Using a bed exit alarm system is a common intervention to minimize the risk of injury in patients with dementia. These systems alert staff when a patient attempts to leave the bed, allowing for timely intervention to prevent falls.

Choice B rationale

Raising four side rails while the patient is in bed is not a recommended practice. This could be considered a form of restraint and could increase the risk of injury if the patient attempts to climb over the rails.

Choice C rationale

Applying one soft wrist restraint is not a recommended practice for patients with dementia. Restraints should be used as a last resort and only when necessary for the patient’s safety.

Choice D rationale

Dimming the lights in the patient’s room is not a recommended practice to minimize the risk of injury in patients with dementia. Adequate lighting can help prevent falls and other accidents.

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A postoperative client refuses to use an incentive spirometer following major abdominal surgery. What is the nurse’s priority action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is conducting a Romberg test as part of a patient’s physical assessment. Which of the following methods should the nurse employ?

Correct Answer is C

Explanation

A nurse is caring for a patient who has dementia. What intervention should the nurse take to minimize the risk of injury to the patient?

Correct Answer is A

Explanation

A nurse is administering fluids to a client.Which of the following assessments should the nurse identify as the priority when monitoring for adverse effects?

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