The nurse is caring for a client with emphysema who is mildly dyspneic after ambulation. Which instruction should the nurse provide to the client to improve gas exchange?
Draw air in through the nose and exhale slowly through pursed lips.
Lay down on each side with knees bent and breathe from the abdomen.
Increase breathing rate for a full 30 seconds.
Raise hands above the head to expand the diaphragm.
The Correct Answer is A
Rationale for Choice A:
Pursed-lip breathing:
Creates back pressure in the airways, which helps to keep them open longer during exhalation.
Slows down the breathing rate, allowing for more complete exhalation and better emptying of the lungs. Prevents air trapping, which can worsen shortness of breath.
Promotes relaxation and reduces anxiety, which can also help to improve breathing.
Rationale for Choice B:
Side-lying position with knees bent:
May not be the most effective position for improving gas exchange in a client with emphysema. Could potentially restrict chest expansion and make breathing more difficult.
May not be comfortable for all clients.
Rationale for Choice C:
Increasing breathing rate:
Can lead to hyperventilation, which can worsen shortness of breath and anxiety. Can also cause fatigue and muscle exhaustion.
Rationale for Choice D:
Raising hands above the head:
Does not significantly expand the diaphragm or improve gas exchange. May actually make breathing more difficult for some clients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Amber urine can be a sign of dehydration, but it is not specific to cholelithiasis with a gallstone lodged in the common bile duct.
While it's important to monitor hydration status in patients with nausea and vomiting, amber urine alone would not be the most urgent finding to report to the healthcare provider in this context.
Choice B rationale:
Belching is a common symptom of gastrointestinal disorders, but it is not specific to cholelithiasis with a gallstone obstruction. It can be caused by various factors, such as swallowing air, eating too quickly, or drinking carbonated beverages.
While belching might be a symptom the nurse documents, it would not be the most concerning finding to report immediately.
Choice C rationale:
Flatulence is another common gastrointestinal symptom that can have various causes, including dietary choices, bacterial fermentation in the intestines, and certain medications.
It is not specific to cholelithiasis with a gallstone obstruction and would not be the most relevant finding to prioritize reporting.
Choice D rationale:
Yellow sclera, also known as jaundice, is a significant finding that strongly suggests cholestasis, which is the obstruction of bile flow.
Bile, a fluid produced by the liver, aids in digestion and gives stool its brownish color.
When bile flow is obstructed, as in the case of a gallstone lodged in the common bile duct, bilirubin (a component of bile) builds up in the bloodstream and tissues, leading to yellowing of the skin and sclera (the whites of the eyes).
This is a crucial finding to report to the healthcare provider because it indicates a worsening of the patient's condition and the need for prompt intervention to address the obstruction.
Correct Answer is C
Explanation
Choice A rationale:
Chronic pain is a significant concern for this client, but it is not the immediate priority. Pain can be managed with medications and comfort measures, while aspiration can be life-threatening.
Tissue destruction by the tumor is likely contributing to the pain, but addressing the risk of aspiration takes precedence.
Uncontrolled pain can exacerbate anxiety and make it difficult to focus on other interventions, but ensuring airway safety is paramount.
Choice B rationale:
Anxiety and grieving are expected reactions to a diagnosis of esophageal cancer, and they should be addressed as part of the client's care plan. However, they are not the immediate priority in this case.
The progression of the disease is a significant stressor, but attending to the risk of aspiration is essential for the client's safety. Psychological distress can negatively impact coping and quality of life, but addressing physical needs takes precedence.
Choice D rationale:
Imbalanced nutrition is a concern for this client due to dysphagia and anorexia. However, it is not the immediate priority. Nutritional interventions can be implemented once the risk of aspiration is addressed.
Difficulty swallowing can lead to inadequate intake and malnutrition, but ensuring airway safety is the primary concern.
Anorexia can further contribute to nutritional deficits, but preventing aspiration is the most pressing issue.
Choice C is the priority nursing problem because:
The client's dysphagia puts them at immediate risk for aspiration, which can lead to pneumonia, respiratory failure, and even death.
Addressing the risk of aspiration is essential to ensure the client's safety and prevent life-threatening complications. It's crucial to implement interventions to minimize the risk of aspiration, such as:
Elevating the head of the bed during meals and for 30-60 minutes after eating Thickening liquids and pureeing foods
Encouraging small, frequent meals
Monitoring for signs of aspiration, such as coughing, choking, or difficulty breathing
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