The nurse is teaching the client to use an incentive spirometer.
What would the nurse include in the teaching plan?

Place the mouthpiece in the mouth and inhale through the mouthpiece.

Set an alarm to ring every hour at night to use the incentive spirometer.

Use the incentive spirometer only when shortness of breath occurs.

Inhale normally and then cough forcefully into the mouthpiece of the device.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The correct technique for using an incentive spirometer involves placing the mouthpiece in the mouth and inhaling slowly and deeply through the mouthpiece. This helps the client to take deep breaths, expand their lungs, and improve lung function. By inhaling through the mouthpiece, the client maximizes the benefits of the incentive spirometer, preventing complications such as atelectasis and pneumonia.

Choice B rationale:

Setting an alarm to ring every hour at night is not relevant to using the incentive spirometer. The frequency of using the incentive spirometer should be determined based on the healthcare provider's recommendation and the client's condition. Using it too frequently or infrequently can both have negative consequences.

Choice C rationale:

Using the incentive spirometer only when shortness of breath occurs is not the correct approach. Incentive spirometry is a preventive measure used to maintain lung function and prevent respiratory complications, especially after surgery. Waiting until shortness of breath occurs might be too late to prevent complications effectively.

Choice D rationale:

Inhaling normally and then coughing forcefully into the mouthpiece of the device is not the correct technique for using an incentive spirometer. Coughing into the device can damage it and render it ineffective. Inhaling deeply and slowly through the mouthpiece is the correct method to encourage optimal lung expansion and prevent respiratory complications.

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Correct Answer is D

Explanation

Choice A rationale:

Avoiding assisting a restless patient to walk does not address the issue of patient confusion and the risk of falling. Restless patients might need assistance, and refusing to help them walk could lead to further complications or falls.

Choice B rationale:

Discouraging the family from staying with the patient does not promote patient safety. Family members can provide additional support and supervision, reducing the risk of falls for a confused patient.

Choice C rationale:

Moving the patient farther away from the nurses' station does not address the patient's confusion or the risk of falling. It might even increase the response time in case of an emergency.

Choice D rationale:

Asking the family about the patient's preferences for movies or music and offering these activities is an appropriate way to engage the patient without resorting to restraints. Providing stimulating and enjoyable activities can help distract and calm the patient, reducing restlessness and the risk of falls.

A. The nurse mistakenly calls the patient's daughter "your wife.”. B. A surgical procedure performed on the wrong leg of a patient. C. The surgical procedure is postponed by 30 minutes. D. The nurse fails to raise the bed to a working height during patient care.

Correct Answer is B

Explanation

Choice A rationale:

The nurse mistakenly calling the patient's daughter "your wife" is a communication error but does not qualify as a sentinel event. Sentinel events are serious, largely preventable patient safety incidents that result in significant harm or death to the patient. Miscommunication, while important to address, does not fall under the category of a sentinel event.

Choice B rationale:

A surgical procedure performed on the wrong leg of a patient is a classic example of a sentinel event. Wrong-site surgery is a serious medical error that can lead to severe consequences for the patient. Proper protocols and procedures, such as time-outs and site marking, are in place to prevent such incidents, making this a sentinel event that requires immediate investigation and analysis to prevent recurrence.

Choice C rationale:

The surgical procedure being postponed by 30 minutes, while potentially inconvenient, does not constitute a sentinel event. Delays in surgical schedules are not uncommon due to various reasons such as emergencies or the complexity of preceding procedures. While delays should be minimized, they do not necessarily result in patient harm or death, making them different from sentinel events.

Choice D rationale:

The nurse failing to raise the bed to a working height during patient care is a safety concern but does not qualify as a sentinel event. It is important for nurses to adhere to proper body mechanics and safety protocols to prevent accidents and injuries. While this situation requires correction and education, it does not meet the criteria of a sentinel event.

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The nurse is teaching the client to use an incentive spirometer.What would the nurse include in the teaching plan?

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The nurse is teaching the client to use an incentive spirometer.
What would the nurse include in the teaching plan?