The nurse is teaching the client about incentive spirometry in the preoperative unit. Which statement regarding incentive spirometry should the nurse include with preoperative teaching?
"Failure to keep your lungs working may result in pneumonia after surgery which could, in turn, result in death."
"Incentive spirometry is conducted routinely after surgery and will be demonstrated when you return from surgery."
"You will use the incentive spirometer for the first postoperative day until deep breathing and coughing can be done comfortably."
"Deep breathing exercises are encouraged to maintain lung capacity and to strengthen respiratory muscles, which will help prevent complications."
The Correct Answer is D
Choice A reason: While it is important to communicate the risks of not using the incentive spirometer, this statement is overly alarming and may cause unnecessary anxiety for the client. It is better to focus on positive outcomes and preventive measures.
Choice B reason: This statement informs the client that incentive spirometry is routine and will be demonstrated postoperatively, but it does not provide specific details about its benefits or importance.
Choice C reason: This statement explains the use of the incentive spirometer on the first postoperative day, but it does not address the overall goal of preventing complications through lung exercises.
Choice D reason: This statement effectively explains the purpose and benefits of deep breathing exercises, including using the incentive spirometer. It emphasizes the importance of maintaining lung capacity and strengthening respiratory muscles to prevent complications, providing a clear rationale for the intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Sending the client to x-ray for a flat plate of the abdomen is important for diagnosing the underlying cause of symptoms, such as bowel obstruction or severe inflammation. However, in the immediate situation, it is essential to relieve the client's symptoms and stabilize their condition first.
Choice B reason: Giving a prescribed analgesic for temperature above 101°F (38.3°C) can help manage fever and pain. However, it is not the first priority. The client’s primary issue is abdominal cramping, nausea, and vomiting, which need to be addressed urgently to prevent further complications.
Choice C reason: Placing an indwelling urinary catheter and attaching it to a bedside drainage unit may be necessary if there are urinary retention concerns. However, this intervention does not directly address the gastrointestinal symptoms that are currently most troubling for the client.
Choice D reason: Inserting a nasogastric tube (NGT) and attaching it to low intermittent suction is the most immediate priority. This action helps to decompress the stomach, relieve nausea and vomiting, and prevent further complications such as aspiration or worsening of the obstruction. It provides immediate symptomatic relief and allows for better management of the client's condition.
Correct Answer is B
Explanation
Choice A reason: Jugular vein distention is more commonly associated with right ventricular heart failure, as it indicates increased central venous pressure.
Choice B reason: Bilateral basilar crackles are a hallmark sign of left ventricular heart failure. They occur due to pulmonary congestion and enema, resulting from the left ventricle's inability to effectively pump blood out to the body, causing fluid to back up into the lungs.
Choice C reason: 3+ pitting enema in the ankles is more characteristic of right ventricular heart failure, where fluid accumulates in the peripheral tissues.
Choice D reason: Hepatomegaly with right upper quadrant (RUQ) tenderness is also more indicative of right ventricular heart failure, as it reflects congestion in the liver due to increased venous pressure.
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