The nurse is performing a physical assessment on the respiratory system. Although the client is currently confined to bed, they have the strength and ability to move and reposition themselves. The nurse instructs the client to assume which position for the assessment?

Sitting upright

Semi-Fowler’s

Supine

Side-lying

Answer and Explanation

The Correct Answer is A

Choice A reason:

Sitting upright is the best position for a respiratory assessment. This position allows for optimal lung expansion and makes it easier to auscultate breath sounds accurately. It also helps in observing the client’s breathing pattern and effort.

Choice B reason:

Semi-Fowler’s position, where the head of the bed is elevated to 30-45 degrees, is often used for clients with respiratory issues to promote lung expansion and reduce the risk of aspiration. However, it is not as effective as the sitting upright position for a thorough respiratory assessment.

Choice C reason:

The supine position, where the client lies flat on their back, is not ideal for a respiratory assessment. This position can limit lung expansion and make it more difficult to hear breath sounds clearly.

Choice D reason:

The side-lying position is also not suitable for a respiratory assessment. This position can cause uneven lung expansion and make it challenging to assess both lungs accurately.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Pursed-lip breathing is a technique used to help manage shortness of breath and improve ventilation. It involves breathing in through the nose and exhaling slowly through pursed lips, as if blowing out a candle. This method helps to keep the airways open longer, allowing more air to escape and reducing the work of breathing.

Choice A reason:

Exhale quickly and forcefully through the mouth is not the correct intervention for pursed-lip breathing. Exhaling quickly and forcefully can cause the airways to collapse, making it harder to breathe out all the air. This can lead to air trapping and increased shortness of breath, which is counterproductive for clients with respiratory issues.

Choice B reason:

Inhale sharply with a “huff” sound is also not correct for pursed-lip breathing. Huff coughing is a technique used to clear mucus from the airways, not to manage breathing patterns. Inhaling sharply can cause irritation and may not provide the controlled breathing needed for effective gas exchange.

Choice C reason:

Inhale deeply through pursed lips is incorrect. The correct technique for pursed-lip breathing involves inhaling through the nose, not through pursed lips. Inhaling through the nose helps to filter and humidify the air, making it easier on the lungs and airways.

Choice D reason:

Exhale slowly through pursed lips is the correct intervention. This technique helps to prolong exhalation, which reduces the respiratory rate and improves ventilation. By keeping the airways open longer, it helps to release trapped air and improve oxygenation. This method is particularly beneficial for clients with chronic obstructive pulmonary disease (COPD) and asthma, as it helps to reduce the work of breathing and improve overall respiratory function.

A. Have a pulse oximetry reading of 95% or greater by discharge. B. Exhibit a respiratory rate of 12-20/minute by discharge. C. Perform self-care activity without dyspnea by discharge. D. Have clear breath sounds bilaterally by discharge.

Correct Answer is C

Explanation

Choice A reason:

Have a pulse oximetry reading of 95% or greater by discharge: While maintaining a pulse oximetry reading of 95% or greater is important, it may not fully address the client’s activity intolerance. Pulse oximetry measures the oxygen saturation in the blood, and normal readings typically range from 95% to 100%. However, achieving this reading alone does not ensure that the client can perform activities without experiencing dyspnea or fatigue.

Choice B reason:

Exhibit a respiratory rate of 12-20/minute by discharge: A normal respiratory rate for adults is between 12 and 20 breaths per minute. While this is a good indicator of respiratory function, it does not directly address the client’s ability to perform self-care activities without dyspnea. The goal should focus on the client’s functional ability rather than just physiological parameters.

Choice C reason:

Perform self-care activity without dyspnea by discharge: This outcome directly addresses the client’s activity intolerance. Dyspnea, or difficulty breathing, is a significant symptom that affects the client’s ability to perform daily activities. By setting a goal for the client to perform self-care activities without dyspnea, the care plan focuses on improving the client’s functional status and quality of life.

Choice D reason:

Have clear breath sounds bilaterally by discharge: Clear breath sounds are an important indicator of improved lung function and resolution of pneumonia. However, this outcome does not specifically address the client’s activity intolerance. While clear breath sounds are desirable, the primary goal should be to ensure the client can perform activities without experiencing dyspnea.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is performing a physical assessment on the respiratory system. Although the client is currently confined to bed, they have the strength and ability to move and reposition themselves. The nurse instructs the client to assume which position for the assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to teach a client how to effectively perform pursed-lip breathing. The nurse would include which intervention in the teaching?

Correct Answer is D

Explanation

A client with left lower lobe pneumonia has activity intolerance related to impaired oxygen supply and demand as evidenced by fatigue, dyspnea, and difficulty performing self-care. Which expected outcome must be included in the care plan related to this problem? The client will:

Correct Answer is C

Explanation

The nurse is aware that the client who is prescribed medications for tuberculosis should have which laboratory test(s) assessed monthly?

A nurse is assessing a newly admitted client whose chief complaint is “coughing up blood” and whose recent history includes a productive cough and night sweats. What is the nurse’s priority intervention?

The nurse recognizes that the goals of teaching about the transmission of tuberculosis have been met when the client with tuberculosis:

Which is the best method for the nurse to correctly identify a client prior to surgery?

The nurse is caring for a client recently diagnosed with emphysema. What information, regarding health maintenance, would the nurse include in teaching sessions? (SELECT ALL THAT APPLY)

The nurse is assessing the client and notes fine crackles throughout the lungs bilaterally. This assessment finding is often associated with:

A nurse is caring for a client prescribed drug N 235 mcg PO daily. Available is drug N PO 0.5 mg per 1 scored tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

The nurse is evaluating the arterial blood gas (ABG) of a client who was admitted in status asthmaticus. Which ABG result would indicate the client has an improved acid-base status?