The nurse knows that teaching about the use of the incentive spirometer is effective when the client seals the lips around the mouthpiece and:

inhales slowly to raise the ball to the desired level and attempts to keep the ball raised for several seconds

blows into the mouthpiece with a long slow expiration to keep the ball at the base of the spirometer,

begins breathing with a rapid. forceful inspiration to raise the ball as high as possible.

exhales slowly to raise the ball to the desired level and quickly inhales to raise the ball again.

Answer and Explanation

The Correct Answer is A

A. Effective use of the incentive spirometer involves slow, sustained inhalation to raise the ball to the desired level and holding the breath for several seconds to fully expand the lungs.

B. Blowing into the mouthpiece is not the correct technique for using an incentive spirometer.

C. Beginning breathing with a rapid, forceful inspiration is not the correct technique for using an incentive spirometer.

D. Exhaling does not raise the ball in the incentive spirometer; it's inhalation that raises the ball to the desired level.

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Correct Answer is B

Explanation

A. Bradycardia, lethargy, and confusion are late signs of hypoxia.

B. Restlessness, confusion, and tachycardia are early signs of hypoxia, indicating the body's attempt to compensate for decreased oxygen levels.

C. Bradycardia, dyspnea, and cyanosis are later signs of hypoxia, indicating more severe oxygen deprivation.

D. Hypotension, vomiting, and cyanosis are also late signs of hypoxia and indicate significant oxygen deprivation.

A. poor tissue perfusion from circulatory insufficiency. B. decreased concentration of oxygen in the air. C. lowered oxygen carrying capacity. D. decreased diffusion of oxygen from the alveoli to the blood.

Correct Answer is D

Explanation

A. Poor tissue perfusion from circulatory insufficiency may contribute to impaired oxygenation, but the major factor in a client with fluid in the lungs is the inability of oxygen to diffuse effectively from the alveoli to the blood.

B. Decreased concentration of oxygen in the air may affect oxygenation, but it is not the major factor in a client with fluid in the lungs.

C. Lowered oxygen-carrying capacity, such as in anemia, can impact oxygenation systemically but is not specific to fluid in the lungs.

D. In a client with fluid in the lungs (pulmonary edema), decreased diffusion of oxygen from the alveoli to the blood is the major factor affecting oxygenation.

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The nurse knows that teaching about the use of the incentive spirometer is effective when the client seals the lips around the mouthpiece and:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse recognizes that the client is manifesting early signs of hypoxia when the assessment data includes:

Correct Answer is B

Explanation

The nurse understands that the major factor affecting oxygenation in a client who has fluid in the lungs is:

Correct Answer is D

Explanation

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