A nurse is teaching a preoperative patient how to use an incentive spirometer. Which instruction should be included in the education to the patient?

Encourage the patient to perform incentive spirometry at least once a shift.

Instruct the patient to inhale normally and then place the lips securely around the mouthpiece and exhale quickly.

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

Instruct the patient to exhale slowly as possible through the mouthpiece without using the nose.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C. Instruct the patient to inhale slowly and as deeply as possible through the mouthpiece without using the nose. Preoperative teaching on how to use an incentive spirometer is important to prevent postoperative respiratory complications such as atelectasis and pneumonia. Inhaling slowly and as deeply as possible through the mouthpiece without using the nose helps to open up the alveoli, promoting oxygen exchange in the lungs. The patient should be instructed to hold their breath for 3-5 seconds before exhaling slowly through the mouthpiece. The procedure should be repeated 10 times every hour while awake.

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

Explanation

A.Observe for signs and symptoms of respiratory distress.

B.Auscultate anterior and posterior lung fields.

C. Inspect the skin for pallor and cyanosis.

E. Observe rate, rhythm, and depth of respirations.

When assessing a client's oxygenation status, a nurse should observe for signs and symptoms of respiratory distress, such as dyspnea, wheezing, and use of accessory muscles. Auscultation of the anterior and posterior lung fields is important to identify any adventitious breath sounds such as crackles, wheezes or rhonchi that may indicate airway obstruction, fluid accumulation, or other respiratory abnormalities. Inspection of the skin is also important to detect pallor or cyanosis, which may indicate reduced oxygen levels in the blood. Lastly, observing the rate, rhythm, and depth of respirations can provide information on the adequacy of oxygen exchange in the lungs.

A. Insert the catheter 2-5 cm and then inflate the balloon. B. Immediately inflate the balloon as soon as urine return is noted. C. Continue to advance the catheter to the bifurcation (Y level of port) and then inflate balloon. D. Insert the catheter until resistance is met, slightly pull back the tubing and then inflate the balloon.

Correct Answer is A

Explanation

The correct answer is choice A. After inserting the catheter 2-5 cm, the nurse should then inflate the balloon. It is important to confirm urine return before inflating the balloon to ensure that the catheter is in the correct position and has not entered the bladder neck or prostate. Inflating the balloon before confirming urine return can cause trauma and increase the risk of infection. Option B is incorrect because inflating the balloon too early can cause discomfort, trauma and increase the risk of infection. Option C is incorrect because advancing the catheter too far can cause injury to the bladder or ureters. Option D is incorrect because pulling back the catheter after meeting resistance can also cause trauma to the urethra.

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A nurse is teaching a preoperative patient how to use an incentive spirometer. Which instruction should be included in the education to the patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is scheduled for a routine physical assessment at the neighborhood clinic. What should the nurse do when physically assessing the client's oxygenation status? Select all that apply.

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

Explanation

The nurse is inserting an indwelling urinary catheter for a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. When should the nurse inflate the balloon?

Correct Answer is A

Explanation

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A nurse is teaching a preoperative patient how to use an incentive spirometer. Which instruction should be included in the education to the patient?

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