The nurse is teaching the client to use an incentive spirometer.
What would the nurse include in the teaching plan?

Place the mouthpiece in the mouth and inhale through the mouthpiece.

Set an alarm to ring every hour at night to use the incentive spirometer.

Use the incentive spirometer only when shortness of breath occurs.

Inhale normally and then cough forcefully into the mouthpiece of the device.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The correct technique for using an incentive spirometer involves placing the mouthpiece in the mouth and inhaling slowly and deeply through the mouthpiece. This helps the client to take deep breaths, expand their lungs, and improve lung function. By inhaling through the mouthpiece, the client maximizes the benefits of the incentive spirometer, preventing complications such as atelectasis and pneumonia.

Choice B rationale:

Setting an alarm to ring every hour at night is not relevant to using the incentive spirometer. The frequency of using the incentive spirometer should be determined based on the healthcare provider's recommendation and the client's condition. Using it too frequently or infrequently can both have negative consequences.

Choice C rationale:

Using the incentive spirometer only when shortness of breath occurs is not the correct approach. Incentive spirometry is a preventive measure used to maintain lung function and prevent respiratory complications, especially after surgery. Waiting until shortness of breath occurs might be too late to prevent complications effectively.

Choice D rationale:

Inhaling normally and then coughing forcefully into the mouthpiece of the device is not the correct technique for using an incentive spirometer. Coughing into the device can damage it and render it ineffective. Inhaling deeply and slowly through the mouthpiece is the correct method to encourage optimal lung expansion and prevent respiratory complications.

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Free Nursing Study Resources

Correct Answer is ["B","C","E"]

Explanation

Choice A rationale:

Restrain the patient with a chemical sedative. Rationale: Restraints, especially chemical sedatives, should be avoided whenever possible due to the risk of complications and patient distress. Restraints can lead to decreased mobility, increased agitation, and other adverse effects. They should only be used as a last resort and with appropriate justification, such as ensuring patient or staff safety in emergency situations.

Choice B rationale:

Encourage the patient to use grab bars located near toilets and showers. Rationale: Installing grab bars in bathrooms helps prevent falls by providing support and stability for patients, especially those with mobility issues. Encouraging their use promotes patient independence and safety while performing essential activities of daily living.

Choice C rationale:

Place the call light within the patient's reach. Rationale: Placing the call light within the patient's reach ensures that the patient can easily summon assistance when needed. Prompt response to patient requests can prevent accidents and falls by addressing the patient's needs in a timely manner.

Choice D rationale:

Conduct rounds every four hours. Rationale: Conducting regular rounds allows healthcare providers to assess the patient's condition, address their needs, and identify potential fall risks. However, the specific frequency of rounds may vary based on the patient's condition and the healthcare facility's policies. Some patients may require more frequent monitoring, especially if they are at a higher risk of falling.

Choice E rationale:

Apply brakes on wheelchairs and beds. Rationale: Applying brakes on wheelchairs and beds prevents unintended movement, enhancing patient safety and reducing the risk of falls. It ensures that the patient's mobility aids remain stationary, providing stability when the patient is transferring or repositioning.

A. Making sure the consent is signed and in the patient's chart in a timely manner. B. Verifying the necessity of the surgical procedure before placing the consent in the chart. C. Asking a family member to translate the consent into the language the patient understands. D. Explaining the risks and benefits of the surgical procedure prior to getting a signature.

Correct Answer is

Explanation

Choice A rationale:

Making sure the consent is signed and in the patient's chart in a timely manner is an important step in the consent process. However, the most appropriate action for the nurse in this situation is to verify the necessity of the surgical procedure before placing the consent in the chart. This is crucial to ensure that the patient fully understands the procedure they are consenting to and that it is medically necessary. Verifying the necessity of the surgical procedure helps in preventing unnecessary procedures, promoting patient safety, and adhering to ethical principles.

Choice B rationale:

Verifying the necessity of the surgical procedure before placing the consent in the chart is the most appropriate action for the newly licensed nurse. This step ensures that the procedure is medically necessary, aligns with the patient's condition, and promotes informed decision-making. By confirming the necessity, the nurse upholds the principle of beneficence, ensuring the patient's well-being, and autonomy, allowing the patient to make informed decisions about their healthcare.

Choice C rationale:

Asking a family member to translate the consent into the language the patient understands might be helpful in improving the patient's understanding of the procedure. However, the primary concern in this situation is verifying the necessity of the surgical procedure. While communication is essential, it does not address the core issue of confirming the medical need for the surgery.

Choice D rationale:

Explaining the risks and benefits of the surgical procedure prior to getting a signature is a vital step in the consent process. However, the question specifically asks for the most appropriate action, which is to verify the necessity of the procedure. Explaining the risks and benefits is an important follow-up step after ensuring the procedure's necessity.

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The nurse is teaching the client to use an incentive spirometer.What would the nurse include in the teaching plan?

Nursing Test Bank

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Correct Answer is

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The nurse is teaching the client to use an incentive spirometer.
What would the nurse include in the teaching plan?