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.

Answer and Explanation

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.

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Correct Answer is ["A","B","D"]

Explanation

Choice A rationale:

Crackles in lung bases Crackles in the lung bases are often indicative of fluid accumulation in the lungs, which can occur in conditions like heart failure. These crackles are discontinuous and sound like "fine rales.”. They can be heard during inspiration and expiration.

Choice B rationale:

Periorbital edema Periorbital edema, or swelling around the eyes, can be a sign of fluid volume overload, especially in the context of an older adult receiving IV therapy. It suggests that excess fluid is accumulating in the body.

Choice D rationale:

Bounding radial pulse A bounding radial pulse is a sign of increased stroke volume and can occur when the heart is working harder to pump the increased blood volume associated with fluid overload.

Choice C rationale:

Swelling at the IV site Swelling at the IV site can be a local reaction and may not necessarily indicate fluid volume overload unless it is associated with other systemic signs.

Choice E rationale:

Flat neck veins when supine Flat neck veins when the client is supine are not typically associated with fluid volume overload. In fact, flat neck veins are more characteristic of hypovolemia. Now, let's address the final question.

A. Low BP and high pulse rate. B. Low BP and low pulse rate. C. High BP and high pulse rate. D. High BP and low pulse rate.

Correct Answer is A

Explanation

Choice A rationale:

Hypovolemic shock is characterized by a decrease in blood volume, leading to low blood pressure and compensatory mechanisms such as a high pulse rate. When the body experiences a significant loss of blood or fluid, it attempts to maintain perfusion to vital organs by increasing the heart rate to ensure an adequate blood supply. Low blood pressure and a high pulse rate are classic signs of hypovolemic shock.

Choice B rationale:

A low BP and low pulse rate are not indicative of hypovolemic shock. Hypovolemic shock is associated with a rapid and weak pulse rate as the body tries to compensate for decreased blood volume. A low pulse rate could suggest other conditions, such as bradycardia, rather than hypovolemic shock.

Choice C rationale:

High BP and high pulse rate are not typical findings in hypovolemic shock. Hypovolemic shock is characterized by low blood pressure and a high pulse rate as the body attempts to compensate for the reduced blood volume. High blood pressure is more commonly associated with conditions like hypertension, not hypovolemic shock.

Choice D rationale:

High BP and low pulse rate are not consistent with the characteristics of hypovolemic shock. As mentioned earlier, hypovolemic shock is marked by low blood pressure and a high pulse rate due to the body's efforts to maintain adequate perfusion. High blood pressure and a low pulse rate may suggest other medical conditions unrelated to hypovolemic shock.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from an older adult who is postoperative and receiving IV therapy at 125 mL/hr. The nurse should identify that which of the following findings indicates the client is experiencing fluid volume overload? (Select all that apply.).

Correct Answer is ["A","B","D"]

Explanation

A nurse is measuring the vital signs of a client he suspects has hypovolemic shock.Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

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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?