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 C

Explanation

Choice A rationale:

The statement that abbreviations are forbidden on a medical record is not entirely accurate. While there are specific abbreviations that should be avoided, not all abbreviations are forbidden. The key is to use recognized and standard abbreviations to prevent misunderstandings.

Choice B rationale:

The statement about using abbreviations only for units of measurement is too restrictive. Abbreviations can be used for various purposes in medical charting, but it is crucial to ensure they are standard, recognized, and widely understood to maintain clarity and patient safety.

Choice C rationale:

Uncommon and unrecognized abbreviations could indeed be misunderstood, leading to misinterpretation of important information. This misunderstanding could compromise patient safety by affecting treatment decisions or medication administration. Using standardized and commonly accepted abbreviations ensures clear communication among healthcare professionals.

Choice D rationale:

Allowing the use of uncommon and unrecognized abbreviations with staff education does not guarantee patient safety. Educating staff about these abbreviations might mitigate some risks, but misunderstandings can still occur, especially in high-stress situations or when dealing with staff turnover. Standardized communication methods are essential to prevent errors.

A. Statements provided by the patient's family. B. Accurate documentation by the nurse. C. Testimony of other nurses. D. Inclusion of expert witnesses.

Correct Answer is B

Explanation

Choice A rationale:

Statements provided by the patient's family are not a reliable defense against nursing negligence. While family statements can offer context, they may not always be accurate or objective. Legal defenses require concrete evidence and accurate documentation.

Choice B rationale:

Accurate documentation by the nurse is the best defense against allegations of nursing negligence. Thorough and precise documentation provides a clear account of the patient's condition, the care provided, and the patient's response. Proper documentation is essential for legal and ethical reasons and serves as a valuable defense in case of legal disputes.

Choice C rationale:

Testimony of other nurses may support the case but may not be as reliable as accurate documentation. Nurse testimony can be subjective and may vary, making it less robust as a defense compared to comprehensive and detailed documentation.

Choice D rationale:

Inclusion of expert witnesses can be helpful, but their testimony is most effective when combined with accurate documentation. Expert witnesses can provide specialized knowledge and opinions, but their credibility is enhanced when supported by thorough and precise nursing documentation.

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

Nursing Test Bank

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Correct Answer is B

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