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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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.

A. Place pillows under the patient's hips and knees before turning. B. Turn the patient only to the right side, never to the left. C. Raise the head of the bed to at least 30 degrees before turning. D. Keep the head, neck, back, hips, and legs in alignment with each other.

Correct Answer is D

Explanation

Choice A rationale:

Placing pillows under the patient's hips and knees before turning is a common practice to maintain proper body alignment during the logrolling procedure. However, it is not the priority step. Placing the pillows is a part of the procedure but does not address the primary concern.

Choice B rationale:

Turning the patient only to the right side and never to the left is incorrect. Patients should be turned gently and carefully to either side, depending on the situation and the patient's condition. Restricting the movement to only one side can cause discomfort and potential injury to the patient.

Choice C rationale:

Raising the head of the bed to at least 30 degrees before turning is a good practice to prevent aspiration and facilitate breathing. However, it is not the priority step when logrolling a patient. Proper body alignment is crucial to prevent musculoskeletal injuries to the patient and the healthcare provider.

Choice D rationale:

The correct answer. Keeping the head, neck, back, hips, and legs in alignment with each other is the nursing priority when logrolling a patient. This technique ensures that the patient's spine is supported and prevents twisting or bending, reducing the risk of injury. Proper body mechanics are essential for both the patient's safety and the healthcare provider's safety during the procedure.

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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

Naxlex Comprehensive Predictor Exams

A newly licensed nurse is obtaining consent for a surgical procedure.Which action by the newly licensed nurse is most appropriate?

Correct Answer is

Explanation

What is the nursing priority when logrolling a patient?

Correct Answer is D

Explanation

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