a nurse is teaching a client postoperative breathing techniques using an incentive spirometer is what should the nurse encourage this client to do to
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Nursing Elites

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Adult Medical Surgical ATI

1. When teaching a client postoperative breathing techniques with an incentive spirometer (IS), what should the nurse encourage the client to do to maintain sustained maximal inspiration?

Correct answer: B

Rationale: To maintain sustained maximal inspiration when using an incentive spirometer, the client should be encouraged to inspire deeply and slowly over 3 to 5 seconds. This technique aids in achieving the goal of sustained maximal inspiration, which is essential for postoperative respiratory recovery.

2. During an assessment, a healthcare professional suspects a client has cholecystitis. What is a common symptom of this condition?

Correct answer: A

Rationale: Right upper quadrant pain is a hallmark symptom of cholecystitis, indicating inflammation of the gallbladder. The gallbladder is typically located in the right upper quadrant of the abdomen, so pain in this area is characteristic of cholecystitis. This pain may be sharp or cramp-like and can be accompanied by other symptoms such as nausea, vomiting, and fever. Left lower quadrant pain (choice B) is more commonly associated with diverticulitis, generalized abdominal pain (choice C) can be seen in various conditions, and epigastric pain (choice D) is typically related to issues in the upper central part of the abdomen, such as gastritis or peptic ulcers, rather than cholecystitis.

3. For a patient with asthma, what is the primary purpose of prescribing salmeterol?

Correct answer: B

Rationale: Salmeterol is classified as a long-acting beta2-agonist, which is used to prevent asthma attacks by providing extended bronchodilation. It is not typically used for immediate relief of acute bronchospasm or for suppressing cough. Additionally, salmeterol does not have the primary purpose of thinning respiratory secretions.

4. The client with bacterial pneumonia is receiving intravenous antibiotics. Which assessment finding indicates that the treatment is effective?

Correct answer: C

Rationale: Clear lung sounds indicate that the antibiotics are effectively treating the bacterial pneumonia by resolving the infection and reducing the inflammation in the lungs, leading to improved air exchange and ventilation. Increased respiratory rate (Choice A) and decreased oxygen saturation (Choice B) are indicative of ongoing respiratory distress and ineffective treatment. Elevated white blood cell count (Choice D) suggests a persistent infection rather than effective treatment.

5. When planning care for a 16-year-old with appendicitis presenting with right lower quadrant pain, what should the nurse prioritize as a nursing diagnosis?

Correct answer: B

Rationale: The priority nursing diagnosis for a client with appendicitis is the 'Risk for infection related to possible rupture of the appendix.' Appendicitis carries a risk of the appendix rupturing, which can lead to peritonitis, a life-threatening condition. Preventing infection through timely intervention and surgery is critical in the care of a client with appendicitis, making this nursing diagnosis the priority.

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