The nurse is providing education to a patient regarding the use of an incentive spirometer. Which patient statement requires further education?
“I will use this device 20 times per hour while I am awake each day."
“I should be in a sitting position when using this device."
“I will hold my breath for 3 seconds after I feel like I cannot inhale any more breath."
“I will exhale completely before placing my lips around the mouthpiece."
The Correct Answer is A
A. "I will use this device 20 times per hour while I am awake each day.": Correct. This statement requires correction. While frequent use is recommended, 10 times per hour is typically sufficient. Overuse may cause hyperventilation or dizziness.
B. "I should be in a sitting position when using this device.": Correct. A sitting or semi-Fowler’s position promotes lung expansion and is the proper position for using an incentive spirometer.
C. "I will hold my breath for 3 seconds after I feel like I cannot inhale any more breath.": Correct. Holding the breath allows for alveolar expansion and better lung recruitment.
D. "I will exhale completely before placing my lips around the mouthpiece.": Correct. Exhaling fully ensures that the next inhalation is deep and effective.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. SOAPIE. This format expands on SOAP (adding Intervention and Evaluation), but SOAP is the core problem-oriented format.
B. ODAR. This is not a recognized problem-oriented charting method.
C. OPIE. This is not a standard documentation method.
D. SOAP. SOAP stands for Subjective, Objective, Assessment, and Plan, and is a commonly used method in problem-oriented medical records.
Correct Answer is D
Explanation
A. The client has a pleasant affect: "Affect" refers to outward emotional expression, whereas "mood" is the client's internal emotional state.
B. The client appears happy with an elevated mood: The nurse should document objective data rather than interpreting the client’s emotions.
C. The client self-isolated today: While self-isolation may indicate mood disturbances, it does not directly document the client’s reported mood.
D. The client rates their mood 4 out of 10: This entry reflects the client’s subjective report using a measurable scale, making it the most accurate documentation.
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