A nurse is educating a postoperative client on how to use an incentive spirometer. What is an accurate statement that should be included in the education plan?

Encourage the client to perform incentive spirometry 2 to 3 times every 1 to 2 hours, if possible.

Instruct the client to inhale slowly and as deeply as possible through the mouthpiece, without using the nose.

Instruct the client to inhale normally and then place the lips securely around the mouthpiece.

When the client cannot inhale anymore, the client should hold his breath and count to 10.

Answer and Explanation

The Correct Answer is B

Choice A reason: Performing incentive spirometry 2 to 3 times every 1 to 2 hours is insufficient. Guidelines recommend 5-10 breaths per session, hourly if possible, to maximize lung expansion and prevent atelectasis. This frequency is too low to effectively improve ventilation, per postoperative pulmonary care protocols.

Choice B reason: Instructing the client to inhale slowly and deeply through the mouthpiece, without using the nose, ensures effective lung expansion. Slow inhalation raises the spirometer’s piston, opening alveoli, while nasal occlusion maximizes airflow. This technique prevents atelectasis, aligning with respiratory therapy and postoperative care guidelines.

Choice C reason: Inhaling normally before placing lips on the mouthpiece is incorrect, as incentive spirometry requires a maximal inspiratory effort, not a normal breath, to expand alveoli. Normal inhalation limits lung volume, reducing the device’s effectiveness in preventing postoperative atelectasis, per pulmonary rehabilitation principles.

Choice D reason: Holding the breath for 10 seconds after inhalation is excessive, as 3-5 seconds is sufficient to sustain alveolar expansion. A prolonged hold may cause discomfort or dizziness, reducing compliance. This instruction does not align with standard incentive spirometry protocols for postoperative lung function improvement.

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Correct Answer is B

Explanation

Choice A reason: Hypertension is defined by elevated blood pressure, not an irregular heart rate. An irregular pattern at 72 bpm suggests a rhythm abnormality, not a pressure issue. Hypertension affects vascular resistance, not cardiac rhythm directly, making this incorrect for the observed finding, per cardiovascular physiology.

Choice B reason: A dysrhythmia is indicated by an irregular heart rate pattern at 72 bpm, as it reflects abnormal electrical conduction, such as atrial fibrillation or premature beats. Notifying the provider is appropriate, as dysrhythmias may impair cardiac output or indicate underlying pathology, requiring prompt evaluation, per cardiac monitoring protocols.

Choice C reason: Tachycardia is a heart rate above 100 bpm, not applicable to 72 bpm. The irregularity, not speed, is the concern. Tachycardia involves rapid but often regular rhythms, whereas this finding suggests a dysrhythmia, making this choice incorrect for the described clinical presentation, per cardiac assessment.

Choice D reason: Bradycardia is a heart rate below 60 bpm, not matching 72 bpm. The irregular pattern points to a dysrhythmia, not a slow rate. Bradycardia affects heart rate frequency, not rhythm irregularity, making this irrelevant to the finding, which requires rhythm-focused intervention, per cardiac physiology.

A. Sodium 138 mEq/L B. Chloride 100 mEq/L C. Potassium 4.1 mEq/L D. Magnesium 1.0 mEq/L

Correct Answer is D

Explanation

Choice A reason: Sodium 138 mEq/L (normal 135-145 mEq/L) is within normal range. Sodium regulates osmotic balance and nerve conduction. Normal levels do not explain tremors, which are often linked to neurological or electrolyte imbalances, like low magnesium. In the context of acute tremors, sodium is not a concern compared to magnesium deficiency.

Choice B reason: Chloride 100 mEq/L (normal 98-106 mEq/L) is normal and does not contribute to tremors. Chloride supports acid-base balance and neuronal inhibition via GABA receptors. Tremors are more likely caused by low magnesium, which affects neuromuscular excitability. Normal chloride levels do not warrant concern in this acute neurological presentation.

Choice C reason: Potassium 4.1 mEq/L (normal 3.5-5.0 mEq/L) is normal and unlikely to cause tremors. Potassium regulates membrane potential and muscle contraction. Tremors are more associated with magnesium deficiency, which increases neuronal excitability. Normal potassium does not explain the neurological symptoms, making it a lower priority than magnesium in this scenario.

Choice D reason: Magnesium 1.0 mEq/L (normal 1.7-2.2 mEq/L) indicates hypomagnesemia, which causes tremors by increasing neuromuscular excitability. Magnesium stabilizes neuronal membranes and regulates calcium channels. Low levels disrupt nerve signaling, leading to tremors and potential seizures. This critical imbalance requires urgent correction, making it the most concerning lab value in this scenario.

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A nurse is educating a postoperative client on how to use an incentive spirometer. What is an accurate statement that should be included in the education plan?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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