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 C

Explanation

The correct answer is choice C, Place all 4 side rails up to prevent the patient from getting out of bed and falling.

When considering alternatives to restraints for a confused and agitated patient who is at high risk for falls, placing all 4 side rails up to prevent the patient from getting out of bed and falling is not an appropriate alternative. This action can be considered as restraint use and can increase the patient's agitation and risk for injury. Instead, the nurse should provide the patient with activities to do while in bed, play music or video selections of the patient's choice, and reduce stimulation noise and light to calm the patient.

A. Documenting an assessment that was not performed B. The nurse documents that the family has asked to speak to the doctor C. The nurse fails to document the doctor's verbal order for a new medication D. The nurse left their badge at home and cannot sign into the EHR E. The nurse documents blood labs were sent before the blood draw was performed

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

Explanation

Correct answers are:

A. Documenting an assessment that was not performed

E. The nurse documents blood labs were sent before the blood draw was performed

Falsification of health records refers to deliberately misrepresenting, fabricating, or altering documentation, which could lead to severe consequences for patients and healthcare providers. In option A, documenting an assessment that was not performed is falsification of health records because it misrepresents the care provided to the patient. Similarly, in option E, documenting that blood labs were sent before the blood draw was performed is a falsification of health records because it is not an accurate representation of the actual order of events.

Options B, C, and D do not involve falsification of health records, but they may be considered documentation errors or violations of organizational policies.

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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

Correct Answer is C

Explanation

Which of the following would be falsification of health records? Select all that apply.

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

Explanation

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