Situation: A 55-year-old woman is scheduled for an elective open cholecystectomy in 4 weeks. At the preoperative clinic visit, she reports smoking 10 cigarettes a day for 20 years. She has type 2 diabetes controlled with metformin. She works as a bookkeeper and says she learns best by doing. The nurse will teach her to use an incentive spirometer, a device she has never seen before. All four actions are part of the plan. Which should the nurse do FIRST?

Teaching a skill starts by gaining the learner's attention and motivation, which for an adult means explaining why the skill matters to her own recovery. The nurse then demonstrates the steps slowly, has her perform a return demonstration with coaching—which suits her preference for learning by doing—and finally gives the recording chart for use after surgery. Her preference changes how much practice she gets, not the order of the steps.

Why the rationale matters first
For an adult learner facing elective surgery, the initial teaching move is not the device itself but the reason for using it. Explaining how incentive spirometry supports lung recovery gives the patient a personally meaningful goal, which is what captures attention and builds readiness to learn. Without that “why,” the steps can feel like an arbitrary task rather than a recovery tool. This aligns with the principle that adult learners engage more fully when they understand the direct benefit to their own health outcome. The patient’s stated preference for learning by doing does not change the sequence; it only means the nurse should allow extra hands-on practice during the return demonstration.

Why the other options come later
Showing the steps (option 2) is the logical next move after motivation is established. Having her practice while the nurse coaches each breath (option 1) follows the demonstration and matches her kinesthetic learning style. Giving her a logging chart (option 3) is the final step, intended for postoperative self-monitoring, not for the initial teaching encounter. Watch out! The question asks what to do first, not which action is most important overall. All four actions belong in the plan, but the sequence begins with explaining the purpose.

How preoperative education connects to outcomes
Preoperative instruction on incentive spirometry has been studied in surgical populations. In one randomized study of joint replacement patients, those who received formal preoperative IS education—including instruction on home use, postoperative use, and volume documentation—were compared with a group that received no preoperative teaching ^[1]. The intervention group was prepared to use the device correctly and track their volumes after surgery. This supports the idea that teaching the purpose and technique before surgery, rather than waiting until afterward, sets the stage for correct use. Similarly, in lung resection patients, preoperative IS training was associated with better postoperative technique and more effective exercise performance compared with those who first encountered the device after surgery ^[2]. The rationale-first approach is consistent with this evidence because a patient who understands why the device matters is more likely to perform the technique correctly when it counts.

The role of correct technique and patient factors
Simply handing a patient an incentive spirometer does not guarantee effective use. A cross-sectional analysis of postoperative patients found that correct inhalation technique was not universal, and factors such as having the device within arm’s reach and having used it were associated with better performance . This underscores why the nurse’s teaching sequence matters: motivation alone is not enough; the patient must also receive a clear demonstration and coached practice. However, the first step remains explaining the benefit, because a patient who does not see the value may not invest effort in mastering the technique. The logging chart (option 3) supports ongoing use but does not address the initial learning gap.

What the evidence does and does not say
A Cochrane review on incentive spirometry after coronary artery bypass graft examined whether IS prevents pulmonary complications, but the available evidence did not establish a clear advantage over other respiratory interventions for that specific population . This does not undermine the teaching sequence for this patient; it simply means the nurse should not overstate the device’s superiority. The teaching goal is correct use of a prescribed intervention, not a claim that IS is better than all alternatives. For this patient scheduled for open cholecystectomy, the nurse’s priority is to ensure she understands the purpose, can perform the technique, and has a plan for postoperative practice.

Putting the sequence together

Step	Action	Rationale
1	Explain how IS helps lung recovery	Builds motivation and relevance for an adult learner
2	Demonstrate the steps slowly	Provides a clear model before practice
3	Have her practice with coaching	Matches her preference for learning by doing
4	Give a chart for logging practice	Supports postoperative self-monitoring

Key point! The patient’s learning preference influences how much practice she receives, not the order of teaching steps. The first action is always to establish the “why” so the learner is ready to engage with the “how.”