A nurse is educating a home care client on how to do pursed-lip breathing. What is the therapeutic effect of this procedure?
Prolongs expiration to reduce airway resistance
Reduces the need for PRN pain medications
Uses upper chest muscles more effectively
Replaces the use of incentive spirometry
The Correct Answer is A
A. Prolongs expiration to reduce airway resistance: Pursed-lip breathing is a technique that slows exhalation, creating back pressure in the airways. This helps prevent airway collapse, particularly in patients with obstructive pulmonary conditions such as COPD, improves alveolar ventilation, enhances gas exchange, and reduces dyspnea. Prolonged expiration also helps decrease air trapping and promotes more effective ventilation.
B. Reduces the need for PRN pain medications: Pursed-lip breathing is not intended to control pain. While relaxation and improved oxygenation may reduce anxiety or discomfort related to dyspnea, it does not have a direct analgesic effect or replace prescribed pain management strategies.
C. Uses upper chest muscles more effectively: The technique primarily focuses on controlled diaphragmatic and lip-controlled exhalation rather than emphasizing upper chest muscle activity. Overusing upper chest muscles can increase fatigue and is not the goal of this breathing technique.
D. Replaces the use of incentive spirometry: Pursed-lip breathing does not serve the same purpose as incentive spirometry, which promotes deep inhalation to prevent atelectasis. While both improve pulmonary function, pursed-lip breathing specifically targets exhalation and airway patency, not inspiratory lung expansion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Respiratory alkalosis: The pH of 7.68 indicates alkalemia, and the PaCO2 is decreased at 30 mmHg, demonstrating a primary respiratory disturbance. The low PaCO2 is consistent with hyperventilation, which causes excessive CO2 exhalation, leading to alkalosis. Although HCO3- is slightly decreased, this likely represents a compensatory metabolic response rather than a primary metabolic disorder, aligning with respiratory alkalosis as the principal abnormality.
B. Respiratory acidosis: Respiratory acidosis is characterized by acidemia (pH <7.35) and elevated PaCO2 (>45 mmHg) due to hypoventilation or impaired gas exchange. In this ABG, the pH is alkalotic and PaCO2 is decreased, which is opposite the pattern seen in respiratory acidosis.
C. Normal ABG results: Normal ABG parameters include pH 7.35–7.45, PaCO2 35–45 mmHg, HCO3- 22–28 mEq/L, and PaO2 80–100 mmHg. This patient’s pH is significantly elevated, PaCO2 is below normal, HCO3- is reduced, and base excess is abnormal, all indicating a pathophysiologic process rather than a normal state.
D. Metabolic acidosis: Metabolic acidosis involves low pH and decreased HCO3- as the primary disturbance. Although HCO3- is reduced at 16.2 mEq/L, the elevated pH and decreased PaCO2 indicate alkalemia with a primary respiratory origin, making metabolic acidosis an incorrect interpretation.
Correct Answer is B
Explanation
A. Administer potassium chloride IV push: Administering potassium as an IV push is extremely dangerous because rapid infusion can cause life-threatening cardiac arrhythmias, including ventricular fibrillation or cardiac arrest. Potassium replacement must be administered slowly and diluted according to protocol, not as a push.
B. Monitor cardiac rhythm: Hypokalemia (K⁺ 3.1 mEq/L) increases the risk of cardiac dysrhythmias, including premature ventricular contractions, atrial fibrillation, and ventricular tachycardia. Continuous cardiac monitoring allows early detection of arrhythmias and guides safe interventions, making this the priority action.
C. Administer a diuretic: Administering a diuretic would further lower potassium levels, worsening hypokalemia and increasing the risk of dysrhythmias. This intervention is contraindicated in this situation and could be harmful.
D. Range of motion exercises: While maintaining mobility is generally beneficial, range of motion exercises do not address the immediate risk of hypokalemia-induced cardiac complications. Cardiac monitoring and safe potassium replacement take priority over non-urgent mobility activities.
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