A nurse is reinforcing preoperative teaching for a client about coughing and deep breathing. Which of the following statements should the nurse make?
"Repeat your breathing exercise every 2 hrs."
"Inhale through your mouth."
"Hold your breath for 5 seconds."
"Exhale through your nose."
The Correct Answer is C
A) "Repeat your breathing exercise every 2 hrs." Repeating breathing exercises should be done a couple of times every hour to help prevent postoperative complications such as atelectasis and pneumonia.
B) "Inhale through your mouth." Clients should inhale through their nose to filter, warm, and humidify the air.
C) "Hold your breath for 5 seconds." Holding the breath for 5 seconds allows for better lung expansion and optimal oxygen exchange.
D) "Exhale through your nose." Clients are generally advised to exhale through pursed lips to create positive airway pressure and prevent airway collapse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Continue to monitor the client: A rise in the water seal with inspiration and fall during expiration (tidaling) is normal in a functioning chest tube system and indicates proper lung expansion.
B. Clamp the chest tube near the water seal: Clamping the tube can cause tension pneumothorax and is not appropriate unless specifically instructed by a provider.
C. Reposition the client and recheck the chamber: Repositioning is unnecessary unless there are signs of obstruction or complications.
D. Add water to the chamber: Water addition is only required if the water level falls below the recommended amount, not in response to normal tidaling.
Correct Answer is D
Explanation
A. Directly over the umbilicus: This position is too low and would not generate effective pressure on the diaphragm.
B. Directly over the sternum: Applying pressure here risks injury to the chest cavity without effectively relieving airway obstruction.
C. Between the umbilicus and the symphysis pubis: This position is too low and ineffective for compressing the diaphragm.
D. Halfway between the xiphoid process and the umbilicus: This is the correct hand placement for the Heimlich maneuver to produce effective inward and upward pressure, dislodging the obstruction.
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