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A nurse is reinforcing teaching about how to use an incentive spirometer with a client. Which of the following statements should the nurse make?
- A. Hold your breath for 7 seconds when using the incentive spirometer.
- B. Sit up at a 30-degree angle when using the incentive spirometer.
- C. Use the incentive spirometer once every 4 hours.
- D. Inhale through the incentive spirometer 10 times with each use.
Correct Answer: A
Rationale: Holding breath for up to 7 seconds maximizes lung expansion, a key goal of incentive spirometry.
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A nurse is reinforcing teaching with a family member about how to position a client when administering enteral feedings at home. Which of the following statements from the family member should the nurse identify as an indication that he understands the instructions?
- A. I will turn my mother on her left side during the feeding.
- B. I will position the head of the bed 45 degrees during the feeding.
- C. I will allow the position my mother finds most comfortable during the feeding.
- D. I will elevate the head of the bed 10 degrees during the feeding.
Correct Answer: B
Rationale: Elevating the bed 45 degrees prevents aspiration and aids digestion during feedings.
A charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene?
- A. The nurse administers the feeding through a syringe barrel by gravity.
- B. The nurse initiates the feeding after aspirating 50 mL of gastric residual.
- C. The nurse allows the client to rest in a supine position during feeding.
- D. The nurse irrigates the NG tube with tap water after feeding.
Correct Answer: C
Rationale: Supine position during feeding increases aspiration risk; semi-Fowler's is recommended.
A nurse is administering an enteral feeding through a client's NG tube. Which of the following actions should the nurse take?
- A. Withhold the feeding if the residual volume is 150 mL
- B. Flush the tube with 30 mL of sterile water before the feeding
- C. Cleanse the top of the can of formula with an alcohol wipe
- D. Keep the formula cold until instillation
Correct Answer: B
Rationale: Flushing with 30 mL of sterile water ensures tube patency and prevents clogging before feeding.
A nurse collecting data from a client who has dehydration. Which of the following findings should the nurse expect?
- A. High blood pressure
- B. Moist skin
- C. Dark-colored urine
- D. Distended neck veins
Correct Answer: C
Rationale: Dark urine indicates dehydration as kidneys concentrate urine to conserve water.
A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?
- A. BUN
- B. Potassium
- C. RBC count
- D. WBC count
Correct Answer: D
Rationale: Elevated WBC count, especially neutrophils, indicates infection response in a pressure ulcer.