The nurse instructing the patient to perform forceful exhalation coughing would instruct the patient to take in:
two deep breaths, then inhale deeply again and force out the air quickly.
one deep breath and quickly exhale
one breath, hold it for 3 seconds, then forcefully exhale three times with mouth open
two breaths and force the air out quickly
The Correct Answer is A
A. Two deep breaths, then inhale deeply again and force out the air quickly: This technique helps clear mucus by mobilizing it toward the larger airways for expulsion.
B. One deep breath and quickly exhale: This method is less effective in mobilizing secretions compared to multiple preparatory breaths.
C. One breath, hold it for 3 seconds, then forcefully exhale three times with mouth open: Holding the breath promotes mucus loosening, and repeated exhalations help clear secretions. While this technique can be correct in some protocols, it is less common for "forceful" cough instructions and may not be the preferred method.
D. Two breaths and force the air out quickly: Lacks the preparatory deep breath necessary for effective secretion clearance.
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 B
Explanation
A) Sternum. Percussion over the sternum is ineffective and may cause discomfort.
B) Thorax. Percussion on the thorax helps loosen mucus in the underlying lung fields.
C) Midaxillary line on the rib cage. This area is not typically targeted for percussion.
D) Spine between the scapulae. Percussion on the spine is not advisable due to the potential for discomfort and ineffectiveness. The area between the scapulae is also less effective for loosening mucus compared to the thorax.
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