The nurse is using home telehealth monitoring to manage care for an 80-year-old who is homebound. The client spends most of their time in bed. Two weeks ago, the nurse detected sacral redness. Last week, it was classified as a Stage 1 pressure ulcer. On this visit, the nurse assesses the sacral area using a video camera, comparing it to the previous visit. Upon noting progression, what should the nurse do next?

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: Donning sterile gloves is unnecessary for abdominal assessment, as it requires clean gloves to prevent infection. Sterile gloves are used for invasive procedures, not palpation or auscultation. This action is irrelevant to preparing for palpation and wastes resources, per infection control and assessment protocols.

Choice B reason: Elevating the patient’s head may relax abdominal muscles but is not required before palpation. Auscultation precedes palpation to avoid altering bowel sounds by pressure. Elevating the head does not address the need for accurate bowel sound assessment, making it less critical, per abdominal examination sequence.

Choice C reason: Percussing all four quadrants follows auscultation and inspection, not precedes palpation. Percussion assesses organ size or fluid but may disrupt bowel sounds if done before auscultation. Auscultation is prioritized to capture unaltered sounds, ensuring a systematic abdominal assessment, per clinical examination guidelines.

Choice D reason: Auscultating bowel sounds before palpation is essential, as palpation may alter peristalsis, leading to inaccurate findings. Listening for hypoactive or hyperactive sounds identifies abnormalities like obstruction, guiding further assessment. This sequence preserves diagnostic accuracy, aligning with systematic abdominal examination protocols.