The nurse would determine that this patient is aware of how to use the incentive spirometer device properly when the patient:

took five quick "huffs" and then coughed vigorously

exhaled deeply and then inhaled quickly and forcefully three times

took five deep breaths slowly every 4 hours

took 10 slow, deep breaths every hour

Answer and Explanation

The Correct Answer is D

A) Took five quick "huffs" and then coughed vigorously. Huff coughing is a technique used to clear secretions, but it is not the correct method for using an incentive spirometer.
B) Exhaled deeply and then inhaled quickly and forcefully three times. Rapid inhalation and exhalation do not promote effective lung expansion or alveolar recruitment.
C) Took five deep breaths slowly every 4 hours. This frequency is insufficient to prevent atelectasis and postoperative lung complications.
D) Took 10 slow, deep breaths every hour. Taking 10 slow, deep breaths every hour encourages full lung expansion and prevents complications such as atelectasis.

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Correct Answer is D

Explanation

A. Perform tracheostomy care for the client every 4 hr: Tracheostomy care is performed based on the assessment of the need for cleaning and secretion management rather than a fixed time schedule.
B. Place the client in a lateral recumbent position prior to tracheostomy care: This position does not facilitate optimal visualization of the tracheostomy site. The Fowler's or semi-Fowler's position is preferred.
C. Clean the tracheostomy stoma with a chlorhexidine solution: Chlorhexidine is too harsh for mucosal surfaces and can cause irritation. Normal saline is recommended for cleaning.
D. Preoxygenate the client for 10 seconds prior to tracheostomy care: Preoxygenation for at least 30 to 60 seconds is recommended to prevent hypoxia during suctioning.

A. directly over the umbilicus B. directly over the sternum C. between the umbilicus and the symphysis pubis D. halfway between the xiphoid process and the umbilicus

Correct Answer is D

Explanation

A. Directly over the umbilicus: This position is too low and would not generate effective pressure on the diaphragm.
B. Directly over the sternum: Applying pressure here risks injury to the chest cavity without effectively relieving airway obstruction.
C. Between the umbilicus and the symphysis pubis: This position is too low and ineffective for compressing the diaphragm.
D. Halfway between the xiphoid process and the umbilicus: This is the correct hand placement for the Heimlich maneuver to produce effective inward and upward pressure, dislodging the obstruction.

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The nurse would determine that this patient is aware of how to use the incentive spirometer device properly when the patient:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

The nurse monitoring patients eating in the dining room of a skilled nursing facility notes that a patient begins choking. As the nurse prepares to deliver the Heimlich maneuver, the fist should be positioned:

Correct Answer is D

Explanation

A nurse is assisting with the care of a client who has a newly inserted chest tube. Which of the following actions should the nurse take?

The nurse is aware that the best time to schedule a postural drainage treatment is

The nurse performing tracheostomy care will:

A nurse is collecting data from a client who has a respiratory disorder and displays manifestations of hypoxia. Which of the following findings should the nurse expect?

A nurse performing oral suctioning on an adult patient should set the wall suction machine so that the suction pressure is between:

The nurse recognizes that a postoperative patient who can breathe independently but has trouble maintaining an airway because of the tongue falling back into the throat would be best benefitted by a(n)

A nurse is reinforcing teaching with a client who has a prescription for home oxygen therapy. Which of the following instructions should the nurse include?

A nurse is checking the suction control chamber of a client's chest tube and notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take?