The nurse is providing preoperative teaching with the client ...

[james]

The nurse is providing preoperative teaching with the client about the use of an incentive spirometer in the postoperative period.
 
  The nurse should include which of the following pieces of information in discussions with the client? Select all that apply. 1. Sit leaning forward.
  2. Inhale deeply and quickly.
  3. Sit upright or lean slightly back.
  4. Hold the mouthpiece tightly with the teeth.
  5. Keep a tight seal between the lips and the mouthpiece.
  6. After maximum inspiration, hold the breath for 2 to 3 seconds and exhale.

Question 2

The nurse notes that the older adult client has a number of bright, ruby-colored, round lesions scattered on the trunk and thighs. The nurse correctly interprets the finding as alterations in blood vessels of the skin and defines them as:
 
  1. Purpura
  2. Venous star
  3. Cherry angioma
  4. Spider angioma

[yotaSR5]

Answer to Question 1

3, 5, 6

Rationale: For optimal lung expansion with an incentive spirometer, the client should assume a semi-Fowler's or high Fowler's position. The mouthpiece should be covered completely with the lips while the client inhales slowly, with a constant flow through the unit. The breath should be held for 2 to 3 seconds before exhaling slowly.

Answer to Question 2

3

Rationale: A cherry angioma occurs with increasing age and has no clinical significance. It is noted by the appearance of small, bright, ruby-colored round lesions on the trunk and/or extremities. Purpura results from hemorrhage into the skin. A venous star results from increased pressure in veins, usually in the lower legs, and has an irregularly shaped bluish center with radiating branches. Spider angiomas have a bright red center, with legs that radiate outward. These are commonly seen in those with liver disease or vitamin B deficiency, although they can occur occasionally without underlying pathology.