The nurse is assisting a patient recovering from surgery on the use of an incentive spirometer. Which patient instruction is appropriate?
a. Do not hold breath after inhaling.
b. Exhale five times before inhaling.
c. Inhale deeply until the target is reached.
d. Exhale deeply until the target is reached.
ANS: C
Instructions for incentive spirometer use include the following: Sit upright, at 45 degrees minimum, if possible. Take two normal breaths. Place mouthpiece of spirometer in mouth. Inhale deeply until target, designated by spirometer light or rising ball is reached, and hold breath for 3 to 5 seconds. Exhale completely. Perform 10 sets of breaths each hour. A. B. D. These are incorrect instructions when teaching on the use of an incentive spirometer.
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A nurse is assessing a pregnant woman who says she drinks 5 to 7 alcoholic drinks per week. What action by the nurse is best?
A. Advise the woman to decrease her drinking to 3 to 4 drinks per week. B. Explain that during pregnancy, alcohol in any amount can harm the fetus. C. Teach her that for women, the safe alcohol limit is 1 drink in an hour. D. Tell the woman to substitute caffeinated beverages for the alcohol.
A nurse is caring for a client who has been the victim of elder abuse by her son. According to the situational
violence theory of elder mistreatment, which of the situations would have occurred? A) The care of the client has overwhelmed son. B) The client was abusive to her son when he was a child. C) The son is an alcoholic. D) The son witnessed his father beating his mother while he was a child.
The nurse who suspects that a client has early signs of ectopic pregnancy should be observing her for which symptoms? (Select all that apply.)
a. Pelvic pain b. Missed period c. Abdominal pain d. Unanticipated heavy bleeding e. Vaginal spotting or light bleeding
The nurse coming on duty gets a laboratory report on an assigned child, and the serum sodium level is reported as 133 milliequivalents per liter (mEq/L). The nurse would expect this client with a 133 mEq/L sodium level to:
a. be experiencing headache, muscle weakness, and abdominal cramps b. have flushed skin, an elevated temperature, and intense thirst c. have a slow pulse rate, decreased respirations, and elevated blood pressure d. appear perfectly normal because this is a normal serum sodium level for a child