A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with emphysema.
Which of the following instructions should be included in the teaching?
Limit fluid intake throughout the day.
Breathe in through her nose and out through pursed lips.
Consume a low-protein diet.
Rest in a supine position.
The Correct Answer is B
Choice A rationale:
Limiting fluid intake throughout the day is not a suitable instruction for a client diagnosed with emphysema. Emphysema is a chronic obstructive pulmonary disease (COPD), and adequate hydration is important for individuals with this condition. Dehydration can lead to thicker mucus in the airways, making it harder to breathe. Clients with emphysema should be encouraged to maintain proper hydration.
Choice B rationale:
Instructing the client to breathe in through her nose and out through pursed lips is a beneficial technique for improving gas exchange in emphysema. This breathing technique, known as pursed-lip breathing, helps slow down the exhalation and maintains positive pressure in the airways, which can prevent airway collapse. It also promotes better oxygen exchange and reduces the feeling of breathlessness.
Choice C rationale:
Consuming a low-protein diet is not advisable for a client with emphysema. Protein is essential for tissue repair and overall health. Clients with emphysema should follow a balanced diet to maintain their energy levels and support their respiratory function. Restricting protein intake is not a standard recommendation for managing emphysema.
Choice D rationale:
Instructing the client to rest in a supine position is not a suitable recommendation. Emphysema clients often find it easier to breathe when in an upright or semi-Fowler's position, as it allows for better lung expansion and oxygen exchange. Resting in a supine position can compromise their ability to breathe effectively and may worsen their symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Restricting visitation is an essential intervention during an influenza outbreak in a long-term care facility. Influenza is highly contagious and can spread rapidly among residents and staff in a close environment like a long-term care facility. By limiting visitation, the facility can reduce the risk of introducing the virus from the outside and help contain the outbreak. This is a preventive measure to protect vulnerable residents from exposure to the virus.
Choice B rationale:
Providing prophylactic antibiotics for clients who have been exposed to influenza is not a recommended intervention. Influenza is caused by a virus, not bacteria, so antibiotics are ineffective in preventing or treating the infection. Antibiotics should only be used to treat bacterial infections, not viral ones. Inappropriate use of antibiotics can lead to antibiotic resistance and other adverse effects.
Choice C rationale:
Implementing airborne precautions for clients who have influenza is not typically necessary. Influenza primarily spreads through respiratory droplets when an infected person coughs or sneezes. Standard precautions, such as proper hand hygiene and wearing masks when in close contact with infected individuals, are usually sufficient to prevent the spread of the virus. Airborne precautions are typically reserved for diseases that are transmitted through the airborne route, like tuberculosis.
Choice D rationale:
Assigning healthcare personnel to nondirect care activities for 24 hours after developing influenza symptoms is not a recommended intervention. While it's important for healthcare personnel to stay home when they are sick to prevent the spread of the virus, 24 hours may not be a necessary duration. The standard guideline for healthcare workers with influenza is to stay home until they are fever-free for at least 24 hours without the use of fever-reducing medications.
Correct Answer is B
Explanation
Choice A rationale:
Hypoglycemia Hypokalemia (low potassium levels) is not typically associated with hypoglycemia (low blood sugar). Hypokalemia primarily affects the function of muscles and nerves, and it does not directly influence blood glucose levels.
Choice B rationale:
Cardiac dysrhythmias Hypokalemia can lead to cardiac dysrhythmias. Potassium plays a crucial role in maintaining the electrical activity of the heart, and low potassium levels can disrupt normal cardiac rhythms, potentially leading to life-threatening arrhythmias. Cardiac dysrhythmias are a well-recognized complication of severe hypokalemia, making this choice the correct one.
Choice C rationale:
Increased appetite Hypokalemia is not associated with an increased appetite. In fact, it can lead to gastrointestinal disturbances, such as nausea, vomiting, and abdominal pain, which may decrease appetite. The primary manifestations of hypokalemia are related to muscle weakness and cardiac abnormalities.
Choice D rationale:
Hyperreflexia Hyperreflexia (excessive reflex responses) is not a typical manifestation of hypokalemia. Hypokalemia is more commonly associated with muscle weakness, cramps, and cardiac disturbances. Hyperreflexia is often seen in conditions of excessive calcium levels (hypercalcemia) or neurological disorders, not hypokalemia.
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