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. Placing protective padding between the client and bed rails is a safety measure to prevent injury during a seizure. This action helps protect the client from head or body trauma if they hit the bed rails or any surrounding surfaces during the seizure.
B. Providing privacy is important for maintaining the client’s dignity during a seizure, but it is not the most immediate concern. The primary focus during a seizure should be on ensuring the client’s safety and monitoring the event. Privacy can be considered once the immediate safety and medical needs are addressed.
C. Observing the client's behavior during the seizure is essential for documentation and subsequent medical evaluation. It helps in identifying the type, duration, and characteristics of the seizure, which is crucial for diagnosis and treatment. However, observation alone does not address immediate safety needs or interventions required during the seizure.
D. Recording the client's level of consciousness after the seizure is important for assessing the postictal state and the extent of recovery. This information is valuable for understanding the impact of the seizure and guiding further medical care. However, during the seizure, immediate actions should focus on ensuring safety and managing the seizure itself.

Correct Answer is []

Explanation

Potential Condition
Urinary Retention
The client's symptoms, including the urge to void, feeling "wet," and the bladder scan showing 600 mL of residual urine, suggest urinary retention. Urinary retention occurs when the bladder does not empty completely or at all, leading to a buildup of urine. This can happen postoperatively due to anesthesia effects, pain, or bladder dysfunction.
Actions to Take
• Request prescription for straight catheter

A straight catheter (intermittent catheterization) is used to drain the bladder and measure the amount of urine collected. It is often preferred over an indwelling catheter in cases of acute urinary retention where temporary relief and assessment of bladder function are needed.
• Insert indwelling urinary catheter
An indwelling urinary catheter might be needed if urinary retention persists and is not relieved by other methods. It allows continuous drainage of urine and can be useful in managing acute or severe cases of urinary retention.
Parameters to Monitor
• Amount of urine output
Monitoring urine output is crucial to evaluate how effectively the bladder is emptying after catheterization or other interventions. This helps in assessing whether the urinary retention is being resolved.
• Residual urine
Checking residual urine with a bladder scanner can help determine how much urine remains in the bladder after voiding. Persistent high residual urine levels would indicate ongoing retention issues that need further intervention.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Correct Answer is []

Explanation

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