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.
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Related Questions
Correct Answer is B
Explanation
A. Pleural effusion: A pleural effusion is the accumulation of fluid in the pleural space and is not directly related to atelectasis. Atelectasis is alveolar collapse and does not cause fluid buildup.
B. Hypoxemia: Atelectasis impairs gas exchange, leading to decreased oxygen levels (hypoxemia) due to collapsed alveoli. This is a hallmark finding.
C. Dysphagia: Dysphagia (difficulty swallowing) is not a direct symptom of atelectasis. It may be seen in stroke or esophageal disorders.
D. Apnea: Apnea (cessation of breathing) is not a typical sign of atelectasis. Atelectasis causes shallow breathing, dyspnea, and hypoxia rather than complete cessation.
Correct Answer is A
Explanation
A. Tell the client to blow his/her nose gently before the instillation of the drops. Blowing the nose clears the nasal passages, allowing the medication to reach the mucosa effectively.
B. Assist the client to a side-lying position. The correct position is head tilted backward (supine with neck hyperextended) or head tilted slightly to the side to ensure proper absorption. A side-lying position is not appropriate for nasal drops.
C. Hold the dropper 2 cm (1 inch) above the nares. The dropper should be placed just inside the nostril without touching it to prevent contamination. Holding it too high may cause the drops to miss the nasal mucosa.
D. Instruct the client to stay in the same position for 2 minutes. Remaining in position for at least 5 minutes allows the medication to be absorbed without draining out of the nasal cavity.
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