As a part of preoperative teaching, the nurse is instructing the ...

[mspears3]

As a part of preoperative teaching, the nurse is instructing the client on the use of a volume-oriented incentive spirometer. Which instruction should be included in this teaching? (Select all that apply.)
 
  1. Blow out into the canister until the enclosed cylinder rises.
  2. Close your lips tightly around the mouthpiece.
  3. Inhale sharply to elevate the enclosed cylinder.
  4. Use a nose clip to occlude nasal passages if necessary.
  5. Cough after using the device.
  6. Tilt the device slightly toward yourself while using.

Question 2

During tracheal suctioning, the nurse notes that the client' heart rate has increased from 80 to 100 bpm. Based upon this assessment, what action should the nurse take?
 
  1. Immediately discontinue suctioning.
  2. Prepare to resuscitate the client.
  3. Continue to suction until the airway is clear.
  4. Complete the suction episode as quickly as possible.

[flexer1n1]

Answer to Question 1

Correct Answer: 2, 4, 5
Rationale : The volume-oriented incentive spirometer works best when the client closes the lips around the mouthpiece tightly, inhales slowly and deeply to achieve rise in the enclosed cylinder, and keeps the device level. A nose clip may be used to occlude nasal passages if the client has difficulty breathing only through the nose. The client should also be taught to cough after using the device.

Answer to Question 2

Correct Answer: 4
Rationale 1: There is no need to immediately discontinue suctioning.
Rationale 2: There is no need to prepare to resuscitate the client.
Rationale 3: The client will likely not tolerate continuing the suction episode until the airway is clear.
Rationale 4: An increase in heart rate from 80 to 100 is not an unusual finding during suctioning, but does indicate increased stress on the client. The nurse should complete the suctioning episode as quickly as possible.

[mspears3]

Excellent

[amcvicar]

TYSM