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When teaching a client how to perform pursed lip breathing, which instructions would the nurse include? (Select all that apply)

Lean on your back with your knees bent.

Use your abdominal muscles to squeeze air out of your lungs.

Breathe out slowly without puffing your cheeks.

Focus on inhaling and holding your breath as long as you can.

Exhale at least twice the amount of time it took to breathe in.

Open your mouth and breathe deeply.

Answer and Explanation

Correct Answer : B,C,E

Choice A: Lean on your back with your knees bent.

Reason: This instruction is incorrect. Pursed lip breathing is typically performed in a seated position with the neck and shoulders relaxed. Lying on your back with knees bent is not a recommended position for this breathing technique.

Choice B: Use your abdominal muscles to squeeze air out of your lungs.

Reason: This instruction is correct. Using the abdominal muscles helps to expel air more effectively from the lungs, which is a key component of pursed lip breathing. This technique helps to improve ventilation and reduce the work of breathing.

Choice C: Breathe out slowly without puffing your cheeks.

Reason: This instruction is correct. Breathing out slowly through pursed lips without puffing the cheeks helps to keep the airways open longer, allowing more air to be expelled from the lungs. This technique is particularly beneficial for individuals with chronic obstructive pulmonary disease (COPD) or other respiratory conditions.

Choice D: Focus on inhaling and holding your breath as long as you can.

Reason: This instruction is incorrect. The focus of pursed lip breathing is on controlled exhalation rather than holding the breath. Inhaling should be done slowly through the nose, and exhaling should be prolonged through pursed lips.

Choice E: Exhale at least twice the amount of time it took to breathe in.

Reason: This instruction is correct. The exhalation phase should be longer than the inhalation phase, typically taking at least twice as long. This helps to improve the efficiency of breathing and reduce shortness of breath.

Choice F: Open your mouth and breathe deeply.

Reason: This instruction is incorrect. Pursed lip breathing involves breathing in through the nose and exhaling through pursed lips. Opening the mouth and breathing deeply is not part of this technique.

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

Explanation

Choice A reason: Pink frothy sputum is a classic sign of pulmonary edema, which can occur as a result of oxygen toxicity. When the alveoli in the lungs fill with fluid, it can lead to this type of sputum. This is a critical indicator that the client is experiencing severe respiratory distress and requires immediate medical attention.

Choice B reason: Substernal discomfort or chest pain is another symptom of oxygen toxicity. This discomfort arises due to the irritation and inflammation of the lung tissues caused by high levels of oxygen. It is essential to monitor and address this symptom promptly to prevent further complications.

Choice C reason: Nail clubbing is typically associated with chronic hypoxia and long-term lung diseases, but it is not an acute indicator of oxygen toxicity. Therefore, it is not relevant in this context.

Choice D reason: Restlessness is a common early sign of hypoxia and can also indicate oxygen toxicity. When the brain does not receive adequate oxygen, it can lead to symptoms such as restlessness, confusion, and agitation. This symptom should be taken seriously and addressed immediately.

Choice E reason: Cyanosis at the nail beds indicates a lack of oxygen in the blood, but it is not specific to oxygen toxicity. It can occur in various conditions where there is inadequate oxygenation, such as chronic obstructive pulmonary disease (COPD) or heart failure.

A. Activate the hospital’s emergency or rapid response system. B. Place a heart monitor on the client and observe for dysrhythmias. C. Ask the charge nurse to come see the client immediately. D. Check the client’s blood pressure and heart rate. E. Provide a calm and assuring environment for the client.

Correct Answer is A

Explanation

Choice A Reason:

Activating the hospital’s emergency or rapid response system is the most appropriate first action in this scenario. The client is exhibiting signs of a potentially life-threatening condition, such as airway obstruction or severe swelling that could compromise breathing. Immediate intervention by a rapid response team can provide the necessary advanced airway management and other critical care measures to stabilize the patient. This action prioritizes the client’s airway, breathing, and circulation, which are the fundamental aspects of emergency care.

Choice B Reason:

Placing a heart monitor on the client and observing for dysrhythmias is important but not the immediate priority in this situation. While monitoring the heart is crucial, the client’s airway and breathing issues take precedence. Addressing the airway obstruction and ensuring adequate breathing should be the first step before focusing on cardiac monitoring.

Choice C Reason:

Asking the charge nurse to come see the client immediately is a reasonable action, but it may delay the necessary urgent intervention. The charge nurse may not have the advanced skills or equipment required to manage a severe airway obstruction. Activating the rapid response system ensures that a team of healthcare professionals with the appropriate expertise and equipment can respond quickly.

Choice D Reason:

Checking the client’s blood pressure and heart rate is a standard nursing assessment, but it is not the immediate priority in this emergency situation. The client’s difficulty breathing and stridor indicate a potential airway obstruction, which requires immediate attention. Ensuring the airway is clear and the client can breathe is more critical than checking vital signs at this moment.

Choice E Reason:

Providing a calm and assuring environment for the client is important for reducing anxiety and stress, but it does not address the immediate life-threatening issue. While maintaining a calm environment is beneficial, the nurse must first ensure that the client’s airway is secure and that they can breathe adequately. This can only be achieved by activating the rapid response system.

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When teaching a client how to perform pursed lip breathing, which instructions would the nurse include? (Select all that apply)

Nursing Test Bank

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