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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 B

Explanation

Choice A Reason:

Documenting that the nasogastric tube is in the correct place is not appropriate in this scenario. The normal pH range for gastric contents is typically between 1.5 and 3.5. A pH of 7.35 is much higher than this range, indicating that the tube may not be in the stomach. Therefore, documenting the tube as correctly placed could lead to potential complications, such as improper feeding or medication administration.

Choice B Reason:

Notifying the health care provider is the correct action. A pH of 7.35 suggests that the nasogastric tube may be misplaced, possibly in the respiratory tract or another non-gastric location. Immediate notification of the health care provider is crucial to prevent any adverse outcomes and to take corrective measures, such as confirming placement with an X-ray or re-inserting the tube.

Choice C Reason:

Checking for placement by auscultating for air injected into the tube is not a reliable method for verifying nasogastric tube placement. While this method was traditionally used, it has been found to be inaccurate and is no longer recommended. The sound of air entering the stomach can be misleading and does not confirm correct placement.

Choice D Reason:

Retesting the pH using another strip is not the best immediate action. While it is important to ensure the accuracy of the pH reading, a pH of 7.35 is significantly outside the normal gastric range, and retesting is unlikely to yield a different result. The priority should be to notify the health care provider to address the potential misplacement of the tube.

A. Hypertension B. Restlessness C. Increased level of alertness D. Tachycardia E. Hypotension F. Bradycardia G. Hypoventilation H. Hyperventilation

Correct Answer is ["E","F","G"]

Explanation

Choice A reason:

Hypertension is not typically associated with myxedema coma. Myxedema coma is characterized by severe hypothyroidism, which usually leads to low blood pressure (hypotension) rather than high blood pressure (hypertension). Therefore, hypertension is not a clinical manifestation that indicates progression to myxedema coma.

Choice B reason:

Restlessness is not a common symptom of myxedema coma. Patients with myxedema coma often present with lethargy, confusion, or even coma due to the severe slowing of metabolic processes. Restlessness is more commonly associated with hyperthyroidism or other conditions that increase metabolic activity.

Choice C reason:

An increased level of alertness is contrary to the symptoms of myxedema coma. Myxedema coma typically presents with decreased mental status, including confusion, stupor, or coma. Therefore, an increased level of alertness would not be indicative of progression to myxedema coma.

Choice D reason:

Tachycardia (rapid heart rate) is not a typical symptom of myxedema coma. Instead, myxedema coma is associated with bradycardia (slow heart rate) due to the severe hypothyroid state. Tachycardia is more commonly seen in hyperthyroid conditions.

Choice E reason:

Hypotension (low blood pressure) is a key clinical manifestation of myxedema coma. The severe hypothyroid state leads to decreased cardiac output and vascular resistance, resulting in hypotension. This is a critical sign that the nurse should recognize as indicative of progression to myxedema coma.

Choice F reason:

Bradycardia (slow heart rate) is another hallmark of myxedema coma. The decreased metabolic rate in severe hypothyroidism leads to a reduced heart rate. Recognizing bradycardia is essential in identifying the progression to myxedema coma.

Choice G reason:

Hypoventilation (reduced breathing rate) is a significant symptom of myxedema coma. The severe hypothyroid state can lead to respiratory depression, resulting in hypoventilation. This can further exacerbate the patient’s condition and requires immediate medical attention.

Choice H reason:

Hyperventilation (increased breathing rate) is not associated with myxedema coma. Patients with myxedema coma typically experience hypoventilation due to the severe slowing of metabolic processes. Hyperventilation would be more indicative of conditions that increase metabolic activity or respiratory drive.

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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

Naxlex Comprehensive Predictor Exams

The nurse is assessing for correct placement of a nasogastric tube. The nurse aspirates the stomach contents, checks the gastric pH, and notes a pH of 7.35. Based on this information, which action should the nurse take at this time?

Correct Answer is B

Explanation

A client has been diagnosed with myxedema from long-standing hypothyroidism. What clinical manifestations of this disorder does the nurse recognize as progressing to myxedema coma? Select all that apply.

Correct Answer is ["E","F","G"]

Explanation

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