NCLEX
The nurse provides instructions to a client about the use of an incentive spirometer. The nurse determines that the client needs further teaching about its use if the client makes which statement?
1."I need to sit upright when using the device." 2. "I will inhale slowly, maintaining a constant flow." 3."I need to place my lips completely over the mouthpiece." 4."After maximal inspiration, I will hold my breath for 10 seconds and then exhale." 4-For optimal lung expansion with the incentive spirometer, the client should assume a semi-Fowler's or high-Fowler's position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. When maximal inspiration is reached, the client should hold the breath for 5 seconds and then exhale slowly through pursed lips
The nurse is preparing to suction an adult client through the client's tracheostomy tube. Which interventions should the nurse perform for this procedure? Select all that apply.
1.Apply suction for up to 10 to 15 seconds. 2.Hyperoxygenate the client before suctioning. 3.Set the wall suction unit pressure at 160 mm Hg. 4.Apply suction while gently inserting the catheter. 5.Apply intermittent suction while rotating and withdrawing the catheter. 6.Advance the catheter until resistance is met and then pull the catheter back 1 cm 1-2-5-6-Intermittent suction is applied while rotating the catheter for 10 to 15 seconds. The nurse should hyperoxygenate the client with a resuscitator bag/Ambu-bag connected to an oxygen source before suctioning because suction depletes the client's oxygen supply (option 2). The catheter should be inserted gently until resistance is met or the client coughs, then pulled back 1 cm or ½ inch. Intermittent suction is applied while rotating and withdrawing the catheter. Option 3 is incorrect because wall suction should be set to 80 to 120 mm Hg. Pressure set at a higher level can cause trauma to respiratory tract tissues. Strict asepsis needs to be maintained, and the nurse would wear sterile gloves to perform this procedure. Suction is never applied when inserting the catheter because it will deplete oxygen and can traumatize tissues
A client newly admitted to the mental health unit describes a recent history of emotional turmoil. The client exhibits physical symptoms and has some loss of physical functioning. The nurse determines that this client is exhibiting signs compatible with which?
1.Depression 2.Somatization disorder 3.Posttraumatic stress disorder 4.Obsessive-compulsive disorder 2-A somatization disorder is characterized by multiple physical complaints involving numerous body systems; the cause of the complaints is presumed to be psychological. The other disorders listed are not associated with the data in the question.
A client with new-onset renal failure is having a first hemodialysis treatment. The nurse is especially careful to monitor the client for which signs/symptoms after the dialysis treatment
1.Hypertension, tachycardia, and fever 2.Hypotension, bradycardia, and hypothermia 3.Restlessness, irritability, and generalized weakness 4.Headache, decreasing level of consciousness, and seizures 4-Disequilibrium syndrome occurs most often in clients who are new to dialysis. It is characterized by headache, mental confusion, decreasing level of consciousness, nausea, vomiting, twitching, and possible seizure activity. It results from rapid removal of solutes from the body during hemodialysis, with a higher residual concentration gradient in the brain because of the blood-brain barrier. Water goes into cerebral cells because of the osmotic gradient, causing brain swelling and the onset of symptoms. It is prevented by dialyzing for shorter times or at reduced blood flow rates.
A health care provider places a Miller-Abbott tube in a client who has a bowel obstruction. Six hours later, the nurse measures the length of the tube outside of the nares and notes that the tube has advanced 6 cm since it was first placed. Based on this finding, which action should the nurse take next?
1.Initiate a tube feeding. 2. Notify the health care provider. 3. Document the finding in the client's record. 4.Pull the tube out 6 cm, and secure the tube to the nose with tape 3-The Miller-Abbott tube is a nasoenteric tube, which is used to decompress the intestine and correct a bowel obstruction. Initial insertion of the tube is a health care provider's responsibility. The tube is weighted by a special substance and either advances by gravity or may be advanced manually. Advancement of the tube can be monitored by measuring the tube and by taking serial x-rays. Options 1, 2, and 4 are incorrect nursing actions. The nurse would, however, keep the registered nurse informed about the progress of the tube advancement.