The nurse is teaching the client about incentive spirometry in the preoperative unit. Which statement regarding incentive spirometry should the nurse include with preoperative teaching?

"Failure to keep your lungs working may result in pneumonia after surgery which could, in turn, result in death."

"Incentive spirometry is conducted routinely after surgery and will be demonstrated when you return from surgery."

"You will use the incentive spirometer for the first postoperative day until deep breathing and coughing can be done comfortably."

"Deep breathing exercises are encouraged to maintain lung capacity and to strengthen respiratory muscles, which will help prevent complications."

Answer and Explanation

The Correct Answer is D

Choice A reason: While it is important to communicate the risks of not using the incentive spirometer, this statement is overly alarming and may cause unnecessary anxiety for the client. It is better to focus on positive outcomes and preventive measures.

Choice B reason: This statement informs the client that incentive spirometry is routine and will be demonstrated postoperatively, but it does not provide specific details about its benefits or importance.

Choice C reason: This statement explains the use of the incentive spirometer on the first postoperative day, but it does not address the overall goal of preventing complications through lung exercises.

Choice D reason: This statement effectively explains the purpose and benefits of deep breathing exercises, including using the incentive spirometer. It emphasizes the importance of maintaining lung capacity and strengthening respiratory muscles to prevent complications, providing a clear rationale for the intervention.

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Correct Answer is A

Explanation

Choice A reason: Describing the use of an elimination diet to find trigger foods is appropriate for clients with Crohn's disease. An elimination diet helps identify foods that may cause or exacerbate symptoms, allowing the client to avoid them and manage their condition more effectively.

Choice B reason: Instructing the client to avoid foods with gluten is not necessarily appropriate unless they have a confirmed gluten intolerance or celiac disease. Gluten avoidance is not a standard dietary restriction for Crohn's disease.

Choice C reason: Advising the client to limit foods that are high in calcium and iron is not appropriate, as these nutrients are important for overall health. Clients with Crohn's disease may need to adjust their diet based on individual needs and deficiencies, but blanket limitations on calcium and iron are not recommended.

Choice D reason: Explaining the need to restrict fluids is not a standard dietary recommendation for Crohn's disease. In fact, staying well-hydrated is important for managing the condition. Fluid restriction may be necessary in specific cases, but it is not a general guideline.

A. Place the client in a darkened room. B. Obtain blood pressure reading. C. Administer an oral analgesic. D. Perform finger stick glucose.

Correct Answer is B

Explanation

Choice A reason: Placing the client in a darkened room may help alleviate symptoms if the headache is related to migraine or sensitivity to light, but it does not address the potential underlying cause of the severe headache and blurred vision in a client with a history of diabetes and hypertension.

Choice B reason: Obtaining a blood pressure reading is the most critical first step. Severe headache and blurred vision can be symptoms of hypertensive crisis, which is a medical emergency that requires immediate attention to prevent complications such as stroke or organ damage. Checking the blood pressure will help determine if the client's symptoms are due to elevated blood pressure.

Choice C reason: Administering an oral analgesic may provide temporary relief for the headache, but it does not address the potential underlying causes of the symptoms. The priority is to assess and manage any potentially life-threatening conditions.

Choice D reason: Performing a finger stick glucose test is important for monitoring blood glucose levels in a client with diabetes. However, in the context of the severe headache and blurred vision, the immediate concern should be to rule out hypertensive crisis by checking the blood pressure first. Blood glucose can be checked after ensuring the client's blood pressure is not critically high.

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The nurse is teaching the client about incentive spirometry in the preoperative unit. Which statement regarding incentive spirometry should the nurse include with preoperative teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond?

Correct Answer is A

Explanation

A client with a history of diabetes mellitus and hypertension received new medication prescriptions three days ago. Today the client returns to the clinic reporting a severe headache and blurred vision. Which intervention should the nurse implement first?

Correct Answer is B

Explanation

A client who has a history of hypothyroidism was admitted with lethargy and confusion. Which additional finding warrants immediate action by the nurse?

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