A nurse is reinforcing teaching with a client who is preoperative following abdominal surgery about deep breathing and coughing exercises. Which of the following client statements should indicate to the nurse an understanding of the instructions?
"I start to use the incentive spirometer when I can get out of bed."
"I breathe deeply and cough every 4 hours."
"I splint my incision with a pillow to cough."
"I lie flat in bed to cough and deep breathe."
The Correct Answer is C
Choice A reason: Using the incentive spirometer is important, but it is not specifically related to deep breathing and coughing exercises.
Choice B reason: Breathing deeply and coughing every 4 hours is part of postoperative care, but it does not indicate understanding of the technique to protect the incision.
Choice C reason: Splinting the incision with a pillow while coughing is a recommended technique to support the incision and reduce pain during coughing, indicating an understanding of the instructions.
Choice D reason: Lying flat is not recommended for deep breathing and coughing exercises as it can inhibit lung expansion and is not conducive to effective coughing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Informed consent is obtained when a patient agrees to a procedure after understanding its risks and benefits, which is what Melva provided.
Choice B reason: A time out is a final review before surgery to ensure correct patient identity, procedure, and site, which is not described here.
Choice C reason: Patient history refers to the collection of a patient's medical background, which is not the focus in this scenario.
Choice D reason: The pre-op checklist is a list of tasks to be completed before surgery, not a discussion of the procedure itself.
Correct Answer is A
Explanation
Choice A reason: Dehiscence refers to the separation of layers of a surgical wound, which may be partial or complete.
Choice B reason: Evisceration is a more severe complication where the wound opens and internal organs may protrude.
Choice C reason: Gaping refers to a wound that is open but does not necessarily indicate the layers have separated, as in dehiscence.
Choice D reason: Distention generally refers to swelling or enlargement of an organ or area, not specifically to the opening of a wound.
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