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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Loop the tubing of the chest tube on the client's bed: Looping can create kinks or blockages, impeding drainage and increasing the risk of complications.
B. Place the chest tube drainage system above the level of the client's heart: This would prevent gravity drainage, leading to fluid accumulation in the pleural space.
C. Strip the client's chest tube every 2 hrs: Stripping can create high negative pressure, damaging lung tissue.
D. Tape the connections on the client's chest tube: Securing all connections with tape helps maintain a closed system and prevents air leaks.
Correct Answer is C
Explanation
A) Milk the chest tube to dislodge any clots in the tubing that may be occluding it. Milking the chest tube is not recommended as it can create excessive negative pressure and damage lung tissue.
B) Notify the provider. This is not the first intervention. The nurse should assess the suction regulator and connections before notifying the provider.
C) Verify that the suction regulator is on. Lack of bubbling often indicates that the suction regulator is off or not functioning correctly. The nurse should first ensure that the regulator is turned on and properly connected.
D) Continue to monitor the client because this is an expected finding. Bubbling should be present in the suction control chamber if suction is applied; therefore, this finding requires immediate assessment.
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