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: Elevating the head of the bed to 90 degrees is crucial for clients in respiratory distress. This position helps to maximize lung expansion, improve breathing, and alleviate respiratory effort. It provides immediate support to enhance oxygenation and ventilation.
Choice B reason: Monitoring pulse oximetry is important for assessing the client's oxygenation status but should be done continuously rather than every 2 hours in a client in respiratory distress.
Choice C reason: Determining exposure to asthmatic triggers is relevant for long-term management but not the immediate priority in an acute situation where the client is in respiratory distress.
Choice D reason: Teaching the proper use of a rescue inhaler is essential but should be done after stabilizing the client's condition. The immediate focus should be on interventions that provide rapid relief from respiratory distress.
Correct Answer is B
Explanation
Choice A reason: Palpating the lymph nodes is not a standard technique for assessing early signs of rheumatoid arthritis. Lymph node enlargement can occur due to various reasons, but it is not specific to rheumatoid arthritis.
Choice B reason: Observing the client's fingers is crucial because early signs of rheumatoid arthritis often present in the small joints of the hands and fingers. Symptoms such as swelling, redness, stiffness, and deformities can be evident in these areas.
Choice C reason: Observing the skin for lesions is not specific to rheumatoid arthritis. While some skin conditions can be associated with autoimmune diseases, rheumatoid arthritis primarily affects the joints.
Choice D reason: Palpating large joints for nodules might be relevant in more advanced stages of rheumatoid arthritis, but early signs are typically observed in the small joints of the hands and fingers.
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