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 ["B","C","E"]
Explanation
Choice A rationale:
Albuterol primarily acts as a bronchodilator by opening up the airways. It does not have a significant anti-inflammatory effect. Inhaled corticosteroids are more commonly used to reduce airway inflammation in asthma.
Choice B rationale:
Albuterol, a beta-2 agonist, helps with breathing by relaxing the smooth muscles in the airways, which opens them up. This action allows for improved airflow and ease of breathing. Therefore, this choice is correct.
Choice C rationale:
Albuterol is used to relieve bronchospasm, which can prevent wheezing in individuals with asthma. It does not have a direct effect on reducing mucus production or coughing.
Choice D rationale:
Albuterol does not increase the amount of mucus production. In fact, it can help reduce coughing by relieving bronchospasm, but it does not directly suppress coughing episodes.
Choice E rationale:
Albuterol can help reduce coughing episodes by improving airflow and reducing the irritation that leads to coughing.
Correct Answer is D
Explanation
The correct answer is Choice D: Headache.
Rationale for Choice D (Headache): Hyponatremia, defined as a serum sodium level below 135 mEq/L, can lead to various neurological symptoms due to the altered osmotic pressure in the brain cells. When the sodium level drops below normal, water moves into the cells, causing them to swell, which can lead to increased intracranial pressure and subsequent headaches. Therefore, a client with a sodium level of 128 mEq/L is likely to experience headaches as a manifestation of hyponatremia.
Rationale for other choices:
Choice A: Hyporeflexia Hyporeflexia refers to diminished or absent reflexes. While hyponatremia can affect neurological function, hyporeflexia is not a typical manifestation. Instead, hyperreflexia may occur in severe cases due to cerebral edema and increased intracranial pressure.
Choice B: Constipation Constipation is not a common manifestation of hyponatremia. Gastrointestinal symptoms such as nausea, vomiting, and abdominal cramping may occur, but constipation is not typically associated with sodium imbalances.
Choice C: Increased appetite Hyponatremia does not typically cause increased appetite. Instead, gastrointestinal symptoms such as nausea and anorexia are more commonly observed. Increased appetite is not directly related to sodium levels but may be seen in conditions such as hyperthyroidism or certain medications.
Therefore, based on the provided data and typical manifestations of hyponatremia, the correct answer is Choice D: Headache. This is because headaches are a common neurological symptom associated with low sodium levels and increased intracranial pressure.
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