The nurse is evaluating the effectiveness of the incentive spirometer implemented in the client's plan of care. Which outcome statement best describes the effectiveness of the incentive spirometer?

Client's breath sounds are clear to auscultation bilaterally.

Client exhibits a frequent productive cough.

Client demonstrates proper use of an incentive spirometer.

Client reports using the incentive spirometer every hour while awake.

Answer and Explanation

The Correct Answer is A

A.   Clear breath sounds indicate effective ventilation and oxygenation, which are the desired outcomes of incentive spirometry. This outcome directly reflects the effectiveness of the incentive spirometer in preventing atelectasis and improving lung expansion.
B.   A productive cough suggests mobilization of secretions. While this is important for airway clearance, it is not a direct measure of the effectiveness of the incentive spirometer. This outcome is related to airway clearance, but not specifically to the incentive spirometer's role in lung expansion.
C.   This outcome measures the client's ability to use the device correctly but does not assess the effectiveness of the device in improving lung function. This outcome is important but does not directly address the goal of the incentive spirometer.
D.   This outcome measures compliance with the therapy but does not assess its effectiveness in improving lung function. This outcome is important for adherence but does not directly address the goal of the incentive spirometer.

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Correct Answer is A

Explanation

A. This is the safest and most accurate option. Insulin dosing is critical, and an overdose can lead to hypoglycemia, a serious condition. By discarding the incorrect dose and starting anew, the nurse ensures the client receives the precise amount of insulin prescribed.
B. This option is inefficient and increases the risk of error. It involves using two different methods for insulin administration, which can lead to confusion and potential mistakes. Additionally, it doesn't address the initial error of dialing the incorrect dose.
C. This option is extremely dangerous. Administering more insulin than prescribed can lead to severe hypoglycemia. Wasting the remaining four units does not rectify the primary issue of the overdose.

D. Insulin pens are designed for precision. Altering the dialed dose after an error can compromise the accuracy of the insulin delivery system. This method is not reliable and can lead to inaccurate dosing.

A. Take the diuretic every day, regardless of weight loss or muscle weakness. B. Weigh yourself daily at the same time and report excessive weight loss. C. Limit fluid intake while taking the diuretic to reduce fluid retention. D. Stop taking the medication when the edema in the lower extremities subsides.

Correct Answer is B

Explanation

A. Diuretics can cause electrolyte imbalances and dehydration, leading to muscle weakness. The patient should report any signs of muscle weakness to the healthcare provider.
B. Weight is a good indicator of fluid loss. Monitoring daily weight and reporting excessive weight loss helps to evaluate the effectiveness of the diuretic and detect potential complications.
C. Limiting fluid intake while on a diuretic can lead to dehydration and electrolyte imbalances. Adequate fluid intake is essential.
D. Diuretics are often prescribed for long-term management of edema. The patient should not stop taking the medication without consulting the healthcare provider.

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The nurse is evaluating the effectiveness of the incentive spirometer implemented in the client's plan of care. Which outcome statement best describes the effectiveness of the incentive spirometer?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When learning to use an insulin pen, a client with diabetes dials 28 units of regular insulin instead of 24 units, the prescribed dose. Which action should the nurse take?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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