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.
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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Related Questions
Correct Answer is C
Explanation
Choice A reason: Stating that talking to the client makes the nurse feel better is inappropriate as it centers on the nurse's emotions rather than the patient’s needs. Communication with dying patients supports dignity, assuming they may retain awareness, which aligns with patient-centered end-of-life care principles.
Choice B reason: Suggesting that talking reduces the nurse’s fear of death is unprofessional and irrelevant. The focus should be on the patient’s potential awareness and dignity. This response dismisses the therapeutic value of communication, which may comfort the patient, per palliative care and psychosocial support guidelines.
Choice C reason: Believing the patient can hear while alive is accurate, as studies suggest hearing persists in dying patients, supporting communication to provide comfort and dignity. This response reflects evidence-based practice, respecting the patient’s potential awareness and aligns with compassionate end-of-life care, per palliative care principles.
Choice D reason: Claiming the family requested talking is inaccurate and deflects responsibility. The rationale should be based on the patient’s potential to hear, supporting dignity. This response lacks a clinical basis and undermines the nurse’s professional judgment in providing meaningful end-of-life communication, per nursing ethics.
Correct Answer is ["A","B","D","E"]
Explanation
Choice A reason: Reduced skin turgor, a sign of fluid volume deficit, occurs due to decreased interstitial fluid, reducing skin elasticity. Dehydration from fluid loss impairs cellular hydration, slowing skin recoil. This is a key assessment finding, as it reflects low extracellular fluid volume, affecting tissue perfusion and requiring fluid replacement to restore homeostasis.
Choice B reason: Decreased blood pressure results from fluid volume deficit, reducing intravascular volume and cardiac output. Low fluid decreases venous return, triggering baroreceptors to signal sympathetic activation, though insufficient to maintain pressure. This is a critical sign, as it indicates compromised perfusion to organs, necessitating fluid resuscitation to restore hemodynamic stability.
Choice C reason: Increased urine output is incorrect, as fluid volume deficit reduces urine output due to decreased renal perfusion. The kidneys conserve fluid via antidiuretic hormone and renin-angiotensin-aldosterone system activation, concentrating urine. This sign does not correlate with dehydration, which typically presents with oliguria, making it an incorrect assessment finding.
Choice D reason: Increased heart rate (tachycardia) compensates for fluid volume deficit, as reduced blood volume lowers cardiac output. Sympathetic activation increases heart rate to maintain tissue perfusion despite low fluid. This is a key sign, reflecting the body’s attempt to compensate for hypovolemia, requiring fluid replacement to normalize cardiovascular function.
Choice E reason: Dry mouth and skin are classic signs of fluid volume deficit, as dehydration reduces salivary gland secretion and skin moisture. Low extracellular fluid impairs mucous membrane hydration and sweat production. These signs indicate systemic fluid loss, affecting cellular function and requiring documentation to guide fluid therapy for restoring hydration and tissue perfusion.
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