Nokea
A nurse is teaching a client about the use of an incentive spirometer. Which of the following instructions should the nurse include in the teaching?
- A. Hold breaths about 3 to 5 seconds before exhaling.'
- B. Exhale slowly through pursed lips.'
- C. Position the mouthpiece 2.5 cm (1 in) from the mouth.'
- D. Place hands on the upper abdomen during inhalation.'
Correct Answer: A
Rationale: Correct Answer: A. Hold breaths about 3 to 5 seconds before exhaling.
Rationale: Holding the breath for a few seconds after inhaling with an incentive spirometer helps to fully expand the lungs and improve lung function. This technique prevents air from escaping too quickly and allows for optimal oxygen absorption. It also encourages deep breathing, which is essential for clearing the airways and improving overall lung capacity.
Summary of other choices:
B: Exhaling slowly through pursed lips is a technique used in pursed lip breathing, not with an incentive spirometer.
C: The position of the mouthpiece is important for comfort but not directly related to using the incentive spirometer.
D: Placing hands on the upper abdomen during inhalation is not a recommended technique for using an incentive spirometer.
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A nurse is assessing a client who has a pressure injury. Which of the following findings should the nurse expect as an indication the wound is healing?
- A. Wound tissue firm to palpation
- B. Dry brown eschar
- C. Light yellow exudate
- D. Dark red granulation tissue
Correct Answer: D
Rationale: The correct answer is D: Dark red granulation tissue. Granulation tissue is a sign of healing in a wound, indicating new blood vessels and collagen formation. Dark red color indicates good blood supply. A: Firm wound tissue can indicate infection or inadequate healing. B: Dry brown eschar is a sign of necrotic tissue, not healing. C: Light yellow exudate can indicate infection or inflammation.
A nurse is caring for a group of clients who are 12 hr postoperative. The nurse should identify that the client who had which of the following procedures is at risk for developing fat embolism syndrome?
- A. Thyroidectomy
- B. Repair of a torn rotator cuff
- C. Internal fixation of a fractured hip
- D. Tympanoplasty
Correct Answer: C
Rationale: The correct answer is C: Internal fixation of a fractured hip. Fat embolism syndrome (FES) typically occurs in long bone fractures or orthopedic surgeries like hip fixation due to fat droplets entering the bloodstream. These fat droplets can travel to the lungs, brain, and other organs, causing respiratory distress, neurological symptoms, and petechial rash. In contrast, choices A, B, and D are not associated with a high risk of FES. Thyroidectomy involves removal of the thyroid gland, repair of torn rotator cuff involves shoulder surgery, and tympanoplasty involves repairing the eardrum, none of which typically lead to fat embolism.
A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg, a fluid intake of 960 mL, and an output of 300 mL in the past 12 hr. Which of the following actions should the nurse take?
- A. Lower the head of the bed to semi-Fowler's.
- B. Administer prescribed corticosteroids.
- C. Slow infusion rate and contact the provider.
- D. Change infusion to lactated Ringer's and maintain rate.
Correct Answer: C
Rationale: Correct Answer: C - Slow infusion rate and contact the provider.
Rationale: The client is showing signs of fluid volume overload with dyspnea, elevated blood pressure, and a significant fluid intake-output discrepancy. Slowing the infusion rate will help reduce fluid intake and potentially prevent worsening of the overload. Contacting the provider is crucial for further assessment and possible adjustment of the treatment plan.
Summary:
A: Lowering the head of the bed may help with respiratory distress but does not address the underlying issue of fluid overload.
B: Administering corticosteroids is not indicated for fluid overload and may worsen the situation.
D: Changing to lactated Ringer's does not address the immediate need to slow down the infusion rate and seek provider guidance.
A nurse is assessing a client who has a chest tube connected to a closed water-seal drainage system. Which of the following findings should the nurse report to the provider?
- A. Constant bubbling in the water seal chamber
- B. Intermittent bubbling in the suction chamber
- C. Clear drainage of 50 mL over 8 hours
- D. Mild pain at the insertion site
Correct Answer: A
Rationale: The correct answer is A: Constant bubbling in the water seal chamber. Constant bubbling in the water seal chamber indicates an air leak in the chest tube system, which can lead to lung collapse or pneumothorax. This finding should be reported to the provider immediately for further evaluation and intervention. Intermittent bubbling in the suction chamber (choice B) is expected and indicates that the suction is working properly. Clear drainage of 50 mL over 8 hours (choice C) is within normal limits and does not require immediate reporting. Mild pain at the insertion site (choice D) is common after a chest tube insertion and can be managed with pain medication.
A nurse is providing teaching to a client who has a new prescription for warfarin. Which of the following medications should the nurse instruct the client to avoid? (Select all that apply)
- A. Ferrous sulfate
- B. Echinacea
- C. Aspirin
- D. Dextromethorphan
- E. Naproxen
Correct Answer: C, E
Rationale: The correct choices are C (Aspirin) and E (Naproxen) because they both increase the risk of bleeding when used with warfarin, an anticoagulant. Aspirin and Naproxen are nonsteroidal anti-inflammatory drugs (NSAIDs) that can further inhibit platelet function and prolong bleeding time, leading to potential complications. Ferrous sulfate (A) is an iron supplement and does not directly interact with warfarin. Echinacea (B) is an herbal supplement with minimal known interactions with warfarin. Dextromethorphan (D) is a cough suppressant and does not impact warfarin's anticoagulant effects. In summary, the nurse should instruct the client to avoid Aspirin and Naproxen to prevent potential bleeding complications when taking warfarin.