Before administering a cleansing enema to an 80-year-old patient, the patient says, “I don’t think I will be able to hold the enema.” Which is the next priority nursing action?

Choice A reason: Pursed lip breathing (PLB) prolongs exhalation to reduce air trapping in COPD but does not directly prevent atelectasis, which is alveolar collapse from shallow breathing or obstruction. PLB maintains positive airway pressure, improving gas exchange, but atelectasis prevention requires deep breathing exercises, making this statement incorrect for PLB’s primary function.

Choice B reason: Pucker the lips like whistling is the correct technique for pursed lip breathing, creating a small opening to slow exhalation. This increases airway pressure, preventing alveolar collapse in COPD and improving oxygen saturation. By prolonging exhalation, PLB reduces hyperinflation, enhancing respiratory efficiency, making this the accurate description of the technique.

Choice C reason: Breathing slowly through the mouth for 4 counts describes inhalation timing, not specific to pursed lip breathing’s exhalation focus. PLB involves nasal inhalation and slow exhalation through pursed lips to reduce air trapping in COPD. Incorrect inhalation instructions can disrupt the technique’s effectiveness in maintaining airway pressure and improving gas exchange.

Choice D reason: Breathing out fast through the mouth for 2 counts contradicts pursed lip breathing’s purpose of slow, controlled exhalation. Rapid exhalation in COPD exacerbates air trapping, worsening hyperinflation. PLB prolongs exhalation through pursed lips to maintain airway pressure, improving oxygenation and reducing respiratory distress, making this statement incorrect.

Choice A reason: Visual acuity measures the clarity of vision, typically tested using a Snellen chart to assess retinal and optic nerve function. Testing cardinal fields of vision evaluates eye muscle coordination, not visual sharpness. This assessment involves cranial nerves III, IV, and VI, not the retina’s ability to resolve fine details, making it irrelevant here.

Choice B reason: Extraocular movements are assessed by testing the cardinal fields of vision, evaluating the coordinated movement of eyes in six directions. This tests cranial nerves III (oculomotor), IV (trochlear), and VI (abducens), which control eye muscles. Misalignment or uncoordinated movement may indicate neurological or muscular issues, making this the correct characteristic being assessed.

Choice C reason: Peripheral vision is tested using confrontation tests, assessing the visual field’s outer edges, mediated by retinal rod cells. Cardinal fields of vision testing focuses on eye muscle coordination, not the extent of the visual field. This assessment does not evaluate peripheral retinal function, making peripheral vision an incorrect choice for this procedure.

Choice D reason: Existence of cataracts is assessed via lens opacity examination, often using an ophthalmoscope. Cardinal fields of vision testing evaluates eye movement coordination, not lens clarity. Cataracts impair light transmission to the retina, but this test targets extraocular muscle function and cranial nerve integrity, making cataract assessment irrelevant to this procedure.