A nurse is providing preoperative teaching about using an incentive spirometer for a client. Which of the following instructions should the nurse include?
"Place the head of the bed flat before using the incentive spirometer."
"Hold your breath for 2 to 3 seconds when using the incentive spirometer."
"Use the incentive spirometer every 3 hours while awake."
"Breathe in through your nose when using the incentive spirometer."
The Correct Answer is B
A. "Place the head of the bed flat before using the incentive spirometer." The client should be in a semi-Fowler’s or high-Fowler’s position (sitting upright) to maximize lung expansion.
B. "Hold your breath for 2 to 3 seconds when using the incentive spirometer." Holding the breath allows for maximum lung expansion and helps prevent atelectasis (lung collapse).
C. "Use the incentive spirometer every 3 hours while awake." The incentive spirometer should be used every 1 to 2 hours while awake to promote lung expansion and prevent complications such as pneumonia.
D. "Breathe in through your nose when using the incentive spirometer." The client should inhale deeply through the mouth, not the nose, to ensure proper lung inflation.
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Related Questions
Correct Answer is C
Explanation
A. Stroking the lower abdomen. This technique is not a recognized method for stimulating urination.
B. Performing Kegel exercises prior to urination. Kegel exercises strengthen pelvic muscles but do not directly promote urination.
C. Pouring warm water over the perineum. Warm water can stimulate sensory nerves and promote relaxation of the urethral sphincter, helping to initiate urination.
D. Leaning backward when sitting and attempting to urinate. The proper posture for urination is sitting upright or leaning slightly forward, not backward.
Correct Answer is D
Explanation
A. "Intensity of pain levels decrease as people age."
Pain perception does not necessarily decrease with age. Older adults experience pain similarly to younger individuals, but they may express it differently.
B. "The client is less likely to respond to analgesics." Older adults respond to analgesics, but they may be more sensitive to certain medications due to age-related physiological changes. Appropriate dosing and monitoring are essential.
C. "Pain is an expected finding for an older adult." Pain is not a normal part of aging. While some chronic conditions associated with aging can cause pain, it should always be assessed and treated appropriately.
D. "The client may under-report their pain intensity."
Older adults may under-report pain due to factors such as fear of being a burden, belief that pain is a normal part of aging, or concerns about medication side effects. Nurses should use appropriate pain assessment tools to evaluate and address their pain effectively.
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