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 C

Explanation

A. Deep breathing and coughing are important for general postoperative care but they are not specifically indicated for immediate postoperative cataract surgery. These exercises can increase intraocular pressure and potentially disrupt the healing process.
B. While it's important to educate caregivers about medication administration, this is not the priority in the immediate postoperative period. The patient should be stable and comfortable before teaching begins.
C. An eye shield is crucial to protect the operated eye from accidental injury during sleep. It prevents rubbing and potential complications.
D. Monitoring vital signs is essential for postoperative care. However, the frequency of every 2 hours is excessive for cataract surgery. Vital signs can be monitored less frequently, depending on the patient's condition.

Correct Answer is ["31"]

Explanation

Total volume in mL x Drop factor) / Total time in minutes.

For the vancomycin infusion, the total volume is 250 mL, the drop factor is 15 gtt/mL, and the total time is 120 minutes (2 hours).

The calculation is as follows: (250 mL x 15 gtt/mL) / 120 minutes = 31.25 gtt/min.

After rounding to the nearest whole number, the nurse should regulate the infusion to 31 gtt/min.

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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

An older adult client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse implement?

Correct Answer is C

Explanation

A client is receiving a secondary infusion of vancomycin 1,500 mg in 250 ml to be infused over two hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the Infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

Correct Answer is ["31"]

Explanation

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