An adult client is assessed as having an apical pulse of 140. How would the nurse document this finding?

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.

Choice A reason: Asking the client’s full name and date of birth ensures accurate identification, aligning with the Joint Commission’s two-identifier protocol. This method confirms the client’s identity directly, reducing medication errors and ensuring safety, as it is reliable and patient-specific, per medication administration standards.

Choice B reason: Verifying the client’s room number is unreliable, as patients may change rooms or share spaces. Room numbers are not unique identifiers and risk misidentification, leading to medication errors. This method fails to meet safety standards for patient verification, per hospital safety protocols.

Choice C reason: Checking the client’s name on the MAR is part of the process but insufficient alone, as it does not confirm the client’s identity at the bedside. Without direct patient verification, errors may occur if MARs are mismatched, making this inadequate, per medication safety guidelines.

Choice D reason: Asking a family member to verify identity is unreliable, as they may be mistaken or unavailable. Direct patient identifiers, like name and date of birth, are required to ensure accuracy, reducing errors. This method does not meet regulatory standards for patient identification, per safety protocols.