The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer

The nurse is conducting preoperative teaching with a client about the use of an incentivespirometer. The nurse should include which piece of information in discussions with the client?The best results are achieved when sitting up or with the head of the bed elevated 45 to 90degrees.Rationale:For optimal lung expansion with the incentive spirometer, the client should assume the semi-Fowler's or high-Fowler's position. The mouthpiece should be covered completely and tightlywhile the client inhales slowly, with a constant flow through the unit. The breath should be heldfor 5 seconds before exhaling slowly.A surgeon is performing an abdominal hysterectomy. Before the surgery is completed, theoperating room nurse counts the sponges and notes that the sponge count is not correlating withthe preoperative count. Which action by the nurse is important?Informing the surgeon of the situationRationale:The surgeon has the ultimate responsibility for the safety of the client and can stop the surgeryuntil the sponge is found. Although documenting is necessary, this is not the most importantaction. Although options 3 and 4 may be appropriate, the surgeon needs to be informed about themissing sponge.A client's preoperative vital signs are temperature 98.6° F (37° C) orally, apical pulse 80 beatsper minute with a regular rhythm, respiration rate 22 breaths per minute, and blood pressure168/94 mm Hg in the right arm. Based on the interpretation of these findings, which actionshould the nurse takefirst?Compare these values to those recorded previously.Rationale:Preoperative assessment of vital signs provides important baseline data with which to comparefollowing surgery. Anxiety and fear commonly cause elevations in the heart rate and bloodpressure. The nurse should review and compare the vital signs to those recorded previously. Thevital signs as stated in the question do not need to be reported to the registered nurseimmediately. The apical pulse is not above the normal range and an apical radial pulse for a fullminute is not required. Rechecking the blood pressure in 5 minutes is likely to show anunchanged blood pressure measurement.

The nurse is preparing a client for a right below-the-knee amputation. The nurse anticipates thatthe client is likely to experience which psychosocial problems in the perioperative period?Selectall that apply.3.Grief4.Anxiety5.Altered body imageRationale:A client facing an elective amputation of a lower extremity will experience psychosocial as wellas physical challenges during the perioperative period. The client is likely to experience griefbecause of the loss of the extremity as well as an alteration in body image. The client will alsoexperience anxiety since this will be a new experience and life as an amputee is unknown. Pain isa physical problem influenced by psychosocial factors. There are no data in the question tosupport a problem of anger.

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Question 74 of 577The nurse is conducting preoperative teaching with a client about the use of an incentivespirometer. The nurse should include which piece of information in discussions with theclient?1.Inhale as rapidly as possible.2.Keep a loose seal between the lips and the mouthpiece.3.After maximum inspiration, hold the breath for 15 seconds and exhale.4.The best results are achieved when sitting up or with the head of thebed elevated 45 to 90 degrees.

Correct Answer: 4Rationale:For optimal lung expansion with the incentive spirometer, the client should assume the semiFowler's or high Fowler's position. The mouthpiece should be covered completely and tightlywhile the client inhales slowly, with a constant flow through the unit. The breath should be heldfor 5 seconds before exhaling slowly.

Question 75 of 577The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week.The client has a history of arthritis and has been taking acetylsalicylic acid. The nursedetermines that the client needs additional teaching if the client makes which statement?

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Question 76 of 577The nurse assesses a client's surgical incision for signs of infection. Which finding by the nursewould be interpreted as a normal finding at the surgical site?

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4.Warm, tender skinCorrect Answer: 2Rationale:Serous drainage is an expected finding at a surgical site. The other options indicate signs ofwound infection. Signs and symptoms of infection include warm, red, and tender skin aroundthe incision. Wound infection usually appears 3 to 6 days after surgery. The client also may havea fever and chills. Purulent material may exit from drains or from separated wound edges.Infection may be caused by poor aseptic technique or a contaminated wound before surgicalexploration; existing client conditions such as diabetes mellitus or immunocompromise mayplace the client at risk.

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What is the purpose of incentive spirometry following surgery Select all that apply?

Which complication would the nurse understand the surgeon is trying to minimize when incentive spirometry has been prescribed for a client after surgery?

Which serious complication can result from retained pulmonary secretions in a postoperative patient?

Which nursing intervention is priority for a client during the immediate postoperative period?