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

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.

A. 2+ Pitting Edema B. 3+ Pitting Edema C. 1+ Non-Pitting Edema D. 4+ Pitting Edema

Correct Answer is D

Explanation

A. 2+ Pitting Edema:This refers to moderate pitting edema where the indentation is approximately 4 mm and disappears within 10-15 seconds.

B. 3+ Pitting Edema:This refers to moderately severe pitting edema where the indentation is approximately 6 mm and may last longer than 1 minute but does not remain for as long as 4 minutes.

C. 1+ Non-Pitting Edema:This grade refers to mild pitting edema with a 2 mm indentation that quickly disappears within a few seconds.

D. 4+ Pitting Edema:4+ pitting edema is characterized by a very deep pit (approximately 8 mm) that may last 2-5 minutes or more. This matches the scenario where the pit is 8 mm deep and remains for 4 minutes.

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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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Naxlex Comprehensive Predictor Exams

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

A nurse is performing a physical assessment of a patient who is experiencing fluid volume excess. Upon examination of the patient's legs, the nurse documents: Pitting edema; 8-mm pit. Pit remained for 4 minutes after pressing. What grade of edema has this nurse documented?

Correct Answer is D

Explanation

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