The nurse is teaching a client with pneumonia about incentive spirometer use. What statement indicates correct understanding?

Correct Answer: B

Rationale: The correct answer is B: "I will inhale deeply into the device to expand my lungs." This statement indicates correct understanding because using an incentive spirometer involves inhaling deeply to fully expand the lungs, promoting better lung ventilation and preventing complications like pneumonia. Choice A is incorrect because using the device once every few hours may not be frequent enough. Choice C is incorrect because the spirometer should be used proactively, not just when feeling short of breath. Choice D is incorrect because exhaling quickly is not the correct technique for using an incentive spirometer.

Correct Answer: A

Rationale: The correct answer is A: Ensuring the reservoir bag remains inflated. This is crucial as it indicates the client is receiving the intended high-flow oxygen without rebreathing exhaled CO2. If the bag deflates, it suggests a leak or inadequate flow. Option B is not relevant as the flow rate for a non-rebreather mask is typically higher. Option C is less critical than ensuring oxygen delivery. Option D is important but not the priority when the client's oxygenation is at stake.

Correct Answer: A

Rationale: The correct answer is A: Oxygen saturation levels. This is the priority assessment because in a client with a history of COPD experiencing increasing dyspnea, it is crucial to assess their oxygen saturation levels to determine if they are hypoxic. Hypoxia can exacerbate COPD symptoms and lead to respiratory distress. Monitoring oxygen saturation levels helps in assessing the effectiveness of respiratory interventions. Choice B (Heart rate and blood pressure) is important but not the priority as hypoxia can directly impact these vital signs. Choice C (Capillary refill time) is more relevant for assessing perfusion in cardiovascular conditions. Choice D (Level of consciousness) is important but assessing oxygen saturation levels takes precedence in a client with COPD and worsening dyspnea.

Correct Answer: A

Rationale: The correct answer is A: Decreased wheezing on auscultation. Wheezing is a common symptom of asthma due to narrowed airways. Improvement in asthma would lead to decreased wheezing as the airways open up, allowing for better airflow. This indicates that the bronchodilator is effectively working to dilate the airways and improve respiratory function. Choice B: Respiratory rate increased to 24 breaths per minute is incorrect as an increased respiratory rate could indicate respiratory distress or worsening of asthma symptoms. Choice C: Heart rate increased to 110 beats per minute is incorrect as an increased heart rate could indicate stress or anxiety, not necessarily improvement in asthma. Choice D: Mild hand tremors reported by the client is incorrect as hand tremors are a common side effect of bronchodilators and not a direct indicator of asthma improvement.

Correct Answer: C

Rationale: The correct answer is C: Keep the patient NPO until the gag reflex returns. After a bronchoscopy with biopsy, the patient's throat and gag reflex may be impaired due to the procedure and anesthesia. Keeping the patient NPO until the gag reflex returns is crucial to prevent aspiration and ensure safe swallowing. Encouraging clear liquids (A) may pose a risk of aspiration if the gag reflex is not intact. Bed rest (B) may not be necessary unless there are specific complications. Maintaining the head of the bed elevated (D) is generally advised for respiratory comfort but is not the immediate priority post-procedure.