A nurse is providing preoperative teaching about using an incentive spirometer for a client. Which of the following instructions should the nurse include?

"Place the head of the bed flat before using the incentive spirometer."

"Hold your breath for 2 to 3 seconds when using the incentive spirometer."

"Use the incentive spirometer every 3 hours while awake."

"Breathe in through your nose when using the incentive spirometer."

Answer and Explanation

The Correct Answer is B

A. "Place the head of the bed flat before using the incentive spirometer." The client should be in a semi-Fowler’s or high-Fowler’s position (sitting upright) to maximize lung expansion.
B. "Hold your breath for 2 to 3 seconds when using the incentive spirometer." Holding the breath allows for maximum lung expansion and helps prevent atelectasis (lung collapse).
C. "Use the incentive spirometer every 3 hours while awake." The incentive spirometer should be used every 1 to 2 hours while awake to promote lung expansion and prevent complications such as pneumonia.
D. "Breathe in through your nose when using the incentive spirometer." The client should inhale deeply through the mouth, not the nose, to ensure proper lung inflation.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Stroking the lower abdomen. This technique is not a recognized method for stimulating urination.
B. Performing Kegel exercises prior to urination. Kegel exercises strengthen pelvic muscles but do not directly promote urination.
C. Pouring warm water over the perineum. Warm water can stimulate sensory nerves and promote relaxation of the urethral sphincter, helping to initiate urination.
D. Leaning backward when sitting and attempting to urinate. The proper posture for urination is sitting upright or leaning slightly forward, not backward.

A. Stop the transfusion. B. Place the client in high-Fowler's position. C. Obtain a prescription for a diuretic. D. Administer oxygen to the client. E. Administer epinephrine to the client.

Correct Answer is ["A","B","C","D"]

Explanation

A. Stop the transfusion. The first action is to stop the transfusion to prevent further fluid overload.
B. Place the client in high-Fowler's position. This position reduces venous return to the heart and improves breathing and oxygenation.
C. Obtain a prescription for a diuretic. Diuretics (e.g., furosemide) help remove excess fluid, relieving pulmonary congestion and reducing strain on the heart.
D. Administer oxygen to the client. Oxygen helps relieve hypoxia caused by fluid buildup in the lungs.
E. Administer epinephrine to the client. Epinephrine is used for anaphylactic reactions, not circulatory overload. There is no indication of an allergic reaction in this scenario.

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A nurse is providing preoperative teaching about using an incentive spirometer for a client. Which of the following instructions should the nurse include?

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