Nokea
A client who is postoperative is being taught how to use a flow-oriented incentive spirometer. Which of the following instructions should be included by the nurse?
- A. Cough deeply after each use.
- B. Take a deep breath and hold for 10 seconds.
- C. Breathe in slowly and deeply to raise the ball or piston.
- D. Exhale forcefully before using the spirometer.
Correct Answer: C
Rationale: The correct technique for using a flow-oriented incentive spirometer involves breathing in slowly and deeply to raise the ball or piston. This action helps to expand the lungs and improve lung function. Option A is incorrect as coughing deeply after each use is not part of using the spirometer. Option B is incorrect as holding the breath for 10 seconds is not the correct instruction for using the spirometer. Option D is incorrect as exhaling forcefully before using the spirometer is not the appropriate step in using this device.
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The client has a nasogastric (NG) tube in place for decompression. What action should the LPN/LVN take to maintain patency of the NG tube?
- A. Irrigate the tube with normal saline every shift.
- B. Check the tube placement by auscultation.
- C. Secure the tube to the client's gown.
- D. Flush the tube with 5 mL of sterile water before and after medication administration.
Correct Answer: A
Rationale: To maintain patency of the NG tube, it is essential to irrigate the tube with normal saline every shift. This action helps prevent clogging and ensures that the tube remains clear for effective decompression. Checking tube placement by auscultation (Choice B) is important for verifying correct placement but does not directly impact patency. Securing the tube to the client's gown (Choice C) is crucial for safety and comfort but is not directly related to maintaining patency. Flushing the tube with sterile water before and after medication administration (Choice D) is not the recommended method for maintaining patency of an NG tube, as normal saline is the appropriate solution for this purpose.
A healthcare professional is planning to collect a liquid stool specimen from a client for ova and parasites. Inaccurate test results may result if the healthcare professional:
- A. Refrigerates the collected specimen
- B. Collects the specimen in a sterile container
- C. Delays the collection of the specimen
- D. Uses a non-contaminated collection container
Correct Answer: A
Rationale: Refrigeration can kill the ova and parasites present in the stool specimen, leading to inaccurate test results. Storing the specimen in a cold environment can disrupt the integrity of the parasites and ova, affecting the accuracy of the test. Collecting the specimen in a sterile container (Choice B) is the correct procedure to prevent external contamination. Delaying the collection of the specimen (Choice C) may affect the freshness of the sample but does not directly impact the test results. Using a non-contaminated collection container (Choice D) is essential to maintain the sample's integrity but does not relate to the risk of killing ova and parasites through refrigeration.
A client is scheduled for an appendectomy and has given informed consent. Which statement by the client should the nurse address first preoperatively?
- A. "I am afraid to walk if it hurts too much."
- B. "I don't understand why I need this surgery."
- C. "I don't want my family helping me after the surgery."
- D. "I am afraid the scar will make me look disfigured."
Correct Answer: B
Rationale: The nurse should address the client's lack of understanding regarding the need for surgery first. Ensuring that the client comprehends the rationale for the procedure is essential for informed consent. Choices A, C, and D, while important, do not directly impact the client's understanding of the necessity of the surgery and can be addressed after clarifying the reason for the procedure.
During preoperative teaching, a client in a surgeon's office expresses intent to prepare advance directives before surgery. Which statement by the client indicates understanding of advance directives?
- A. "I'd prefer my brother to make decisions, but I understand it must be my wife."
- B. "I understand the surgery won't proceed unless I fill out these forms."
- C. "I plan to specify my wish to avoid being kept on a breathing machine."
- D. "I will have my primary doctor review my plan before submitting it at the hospital."
Correct Answer: C
Rationale: The correct answer is C. This statement reflects the client's understanding of advance directives, as it indicates a specific preference regarding life-sustaining treatment. Advance directives enable individuals to outline their healthcare preferences, including decisions about treatments they wish to receive or avoid. Choice A mentions family members but doesn't address specific healthcare wishes; choice B focuses on the surgery rather than personal directives; choice D discusses doctor approval but lacks details about the directive itself.
A client is being taught about medications at discharge. Which statement should the nurse identify as an indication that the client understands the instructions?
- A. I can open the time-release capsule with the beads in it and sprinkle them on my oatmeal.
- B. If I am having difficulty swallowing, I will add the liquid medication to a prepared package of pudding.
- C. I can crush the enteric-coated pill if needed.
- D. I will eat two crackers with the pain pills.
Correct Answer: B
Rationale: The correct answer is B. Adding liquid medication to pudding can help with swallowing difficulties, demonstrating understanding of the instructions. Options A and C are incorrect as altering time-release capsules and enteric-coated pills is not recommended in medication administration. Option A is incorrect as time-release capsules should not be opened and sprinkled on food, affecting their efficacy. Option C is incorrect as crushing enteric-coated pills can affect their absorption. Option D is unrelated to medication administration and does not demonstrate understanding of the instructions.