A nurse is teaching a preoperative patient how to use an incentive spirometer. Which instruction should be included in the education to the patient?

Encourage the patient to perform incentive spirometry at least once a shift.

Instruct the patient to inhale normally and then place the lips securely around the mouthpiece and exhale quickly.

Instruct the patient to inhale slowly and as deeply as possible through the mouthpiece without using the nose.

Instruct the patient to exhale slowly as possible through the mouthpiece without using the nose.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C. Instruct the patient to inhale slowly and as deeply as possible through the mouthpiece without using the nose. Preoperative teaching on how to use an incentive spirometer is important to prevent postoperative respiratory complications such as atelectasis and pneumonia. Inhaling slowly and as deeply as possible through the mouthpiece without using the nose helps to open up the alveoli, promoting oxygen exchange in the lungs. The patient should be instructed to hold their breath for 3-5 seconds before exhaling slowly through the mouthpiece. The procedure should be repeated 10 times every hour while awake.

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Correct Answer is D

Explanation

The correct answer is choice D. The description of full-thickness skin and tissue loss with exposed muscle, tendon, and bone in the ulcer indicates a pressure ulcer that is categorized as stage IV. In this stage, the ulcer is characterized by fullthickness tissue loss, exposing muscle, bone, or tendons. Stage I (choice A) pressure injuries involve non-blanchable erythema of intact skin. Stage II (choice B) pressure injuries involve partial-thickness skin loss, which can involve the epidermis, dermis, or both. Stage III (choice C) pressure injuries involve fullthickness tissue loss, but not bone, tendon, or muscle. Therefore, based on the description provided, the pressure ulcer is categorized as stage IV.

A. Act as if you are still taking the radial pulse while assessing respiratory rate so the client does not know you are counting. B. If the respiratory rate is regular, count for 30 seconds and multiply by 2. C. Observe the depth and rhythm of the respirations. D. Count a full respiratory cycle (inhalation and exhalation) E. Count a full respiratory cycle (inhalation and exhalation)

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

Explanation

The correct answer is choices B, C, and D.

When assessing respiratory rate, it is important to count for a full respiratory cycle, which includes both inhalation and exhalation. If the respiratory rate is regular, the nurse can count for 30 seconds and multiply by 2 to obtain the total number of breaths per minute. The nurse should also observe the depth and rhythm of the respirations, noting any abnormalities or changes. It is not recommended to pretend to take the radial pulse while assessing respiratory rate, as this can lead to inaccurate readings and is not a professional approach to care

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A nurse is teaching a preoperative patient how to use an incentive spirometer. Which instruction should be included in the education to the patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse assesses a patient's pressure injury and documents the following: fullthickness skin and tissue loss with exposed muscle, tendon, and bone in the ulcer. This pressure ulcer is categorized to be at which of the following stages?

Correct Answer is D

Explanation

A nurse is instructing a group of nursing students in taking vital signs and assessing a client's respiratory status. Which of the following guidelines should the nurse include? Select all that apply.

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

Explanation

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