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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Report by patient that something has given way: A patient reporting a "giving way" sensation is a classic early sign of dehiscence, indicating that the wound edges are separating.

B. Drainage that is odorous and purulent: Purulent (pus-like) and foul-smelling drainage suggests infection, not necessarily dehiscence. Infection can contribute to dehiscence, but it is not the defining feature.

C. Protrusion of visceral organs through a wound opening: Evisceration occurs when internal organs protrude through the incision. Dehiscence is partial or complete separation of the wound edges without organ protrusion.

D. Chronic drainage of fluid through the incision site: Persistent drainage suggests a fistula (abnormal connection between tissues), infection, or poor wound healing, rather than wound dehiscence.

A. Explain the procedure to the child. B. Choose the cuff that says "Child" instead of "Infant." C. Use the diaphragm portion of the stethoscope to detect Korotkoff sounds. D. Obtain the reading before the child has a chance to settle down

Correct Answer is A

Explanation

A. Explain the procedure to the child. Explaining procedures in an age-appropriate manner helps reduce anxiety and increases cooperation. A 3-year-old can understand simple instructions, so explaining what will happen can help them remain calm.

B. Choose the cuff that says "Child" instead of "Infant." Blood pressure cuffs should be appropriately sized for accurate readings. A cuff that is too small can result in falsely high readings, while a cuff that is too large can produce falsely low readings.

C. Use the diaphragm portion of the stethoscope to detect Korotkoff sounds. The bell of the stethoscope is best for detecting low-pitched sounds, including Korotkoff sounds.

D. Obtain the reading before the child has a chance to settle down. A child who is upset, crying, or anxious may have an elevated blood pressure reading due to stress. It is best to allow the child to calm down before obtaining an accurate measurement.

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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?

Nursing Test Bank

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