The nurse is teaching the client about incentive spirometry in the preoperative unit. Which statement regarding incentive spirometry should the nurse include with preoperative teaching?
"Failure to keep your lungs working may result in pneumonia after surgery which could, in turn, result in death."
"Incentive spirometry is conducted routinely after surgery and will be demonstrated when you return from surgery."
"You will use the incentive spirometer for the first postoperative day until deep breathing and coughing can be done comfortably."
"Deep breathing exercises are encouraged to maintain lung capacity and to strengthen respiratory muscles, which will help prevent complications."
The Correct Answer is D
Choice A reason: While it is important to communicate the risks of not using the incentive spirometer, this statement is overly alarming and may cause unnecessary anxiety for the client. It is better to focus on positive outcomes and preventive measures.
Choice B reason: This statement informs the client that incentive spirometry is routine and will be demonstrated postoperatively, but it does not provide specific details about its benefits or importance.
Choice C reason: This statement explains the use of the incentive spirometer on the first postoperative day, but it does not address the overall goal of preventing complications through lung exercises.
Choice D reason: This statement effectively explains the purpose and benefits of deep breathing exercises, including using the incentive spirometer. It emphasizes the importance of maintaining lung capacity and strengthening respiratory muscles to prevent complications, providing a clear rationale for the intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Describing the use of an elimination diet to find trigger foods is appropriate for clients with Crohn's disease. An elimination diet helps identify foods that may cause or exacerbate symptoms, allowing the client to avoid them and manage their condition more effectively.
Choice B reason: Instructing the client to avoid foods with gluten is not necessarily appropriate unless they have a confirmed gluten intolerance or celiac disease. Gluten avoidance is not a standard dietary restriction for Crohn's disease.
Choice C reason: Advising the client to limit foods that are high in calcium and iron is not appropriate, as these nutrients are important for overall health. Clients with Crohn's disease may need to adjust their diet based on individual needs and deficiencies, but blanket limitations on calcium and iron are not recommended.
Choice D reason: Explaining the need to restrict fluids is not a standard dietary recommendation for Crohn's disease. In fact, staying well-hydrated is important for managing the condition. Fluid restriction may be necessary in specific cases, but it is not a general guideline.
Correct Answer is B
Explanation
Choice A reason: Applying soft restraints to all extremities is not appropriate during a seizure as it can increase the risk of injury. The priority is to ensure the client's safety by preventing injury without restraining them.
Choice B reason: Removing objects that could cause injury is crucial. During a seizure, the client may move unpredictably, and any nearby objects could pose a risk of harm. Clearing the area ensures the client has a safe space to have the seizure without additional hazards.
Choice C reason: Placing pillows around the client's head can provide some protection, but it is not as immediately effective or necessary as removing potentially harmful objects from the surrounding area. Ensuring a clear and safe environment is the primary concern.
Choice D reason: Administering oxygen per nasal cannula is not the first priority during a seizure. While maintaining oxygenation is important, the immediate focus should be on ensuring the client's physical safety by removing dangerous objects. Once the seizure subsides, appropriate respiratory support can be provided if needed.
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