A nurse is providing preoperative teaching by demonstrating diaphragmatic breathing to a client who is scheduled for surgery in the morning. Which of the following actions should the nurse include in the demonstration?
Hold her breath for at least 10 seconds.
Place her hands on the sides of her rib cage.
Exhale forcefully through the nose.
Inhale slowly and evenly through her nose.
The Correct Answer is D
A. Hold her breath for at least 10 seconds. Diaphragmatic breathing focuses on slow, deep breaths to promote lung expansion and oxygenation. Holding the breath is not part of this technique and may increase discomfort.
B. Place her hands on the sides of her rib cage. While hand placement is encouraged, the correct position is on the abdomen (below the rib cage), not the sides. This helps the client feel the diaphragm expanding.
C. Exhale forcefully through the nose. Exhalation should be slow and controlled through the mouth, not forceful through the nose, to prevent airway irritation.
D. Inhale slowly and evenly through her nose. The correct technique for diaphragmatic breathing is to inhale deeply through the nose while the abdomen expands. This promotes lung expansion and prevents atelectasis postoperatively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Stage I Pressure Ulcer: A Stage III pressure ulcer does not regress to a Stage I as it heals. It retains its original staging classification.
B. Stage III Pressure Ulcer: While the ulcer was originally Stage III, documenting it this way without specifying healing progress does not accurately reflect its current condition.
C. Healing Stage III Pressure Ulcer: Pressure ulcers are documented at their worst stage, even as they heal. The correct terminology includes "healing" to show improvement.
D. Healing Stage II Pressure Ulcer: A Stage III ulcer does not become a Stage II ulcer as it heals; instead, it is called a healing Stage III pressure ulcer.
Correct Answer is B
Explanation
A. Relying on recall of information from past lectures and textbooks. Critical thinking involves applying knowledge, not just recalling it. Nurses must analyze patient-specific data and adapt care accordingly.
B. Using the nursing process. The nursing process (assessment, diagnosis, planning, implementation, evaluation) is a structured approach that guides clinical decision-making and ensures patient-centered care.
C. Drawing on past clinical experiences to formulate standardized care plans. Past experiences can inform decision-making, but care plans must be individualized to the patient’s current condition rather than relying solely on standardization.
D. Depending on the charge nurse to determine priorities of care. While charge nurses provide leadership, each nurse is responsible for critical thinking and independent decision-making based on their assessment.
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