The nurse is preparing to teach a client how to effectively perform pursed-lip breathing. The nurse would include which intervention in the teaching?
Exhale quickly and forcefully through the mouth.
Inhale sharply with a “huff” sound.
Inhale deeply through pursed lips.
Exhale slowly through pursed lips.
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Telling the patient to “try to go as long as possible before you press the button” is not advisable. PCA devices are designed to allow patients to manage their pain effectively by administering medication as soon as they begin to feel discomfort. Delaying the use of the PCA can lead to uncontrolled pain, which can be more difficult to manage later.
Choice B reason:
“Instruct your family or visitors to press the button for you when you are sleeping” is incorrect and potentially dangerous. Only the patient should press the PCA button to ensure that they are receiving the medication when they actually need it. Allowing others to press the button can lead to overmedication and serious side effects.
Choice C reason:
“Push the button every 15 minutes whether you feel pain at that time or not” is also incorrect. PCA devices are intended to be used on an as-needed basis. Pressing the button at regular intervals without experiencing pain can result in unnecessary medication administration and potential overdose.
Choice D reason:
“Push the button when you begin to feel pain, instead of waiting until the pain becomes worse” is the correct instruction. This approach helps to manage pain more effectively by preventing it from becoming severe. Early intervention with pain management can lead to better overall outcomes and patient comfort.
Correct Answer is B
Explanation
Choice A reason: Elevating the client’s head of the bed to 45 degrees is important for promoting optimal lung expansion and reducing the risk of aspiration. However, it is not the first priority when preparing for tracheostomy care. Ensuring adequate oxygenation is more critical in the immediate preparation phase.
Choice B reason: Hyper-oxygenating the client using an Ambu bag is the first priority. This step is crucial to ensure that the client has sufficient oxygen reserves before the tracheostomy care procedure begins. Hyper-oxygenation helps prevent hypoxia during suctioning, which can be particularly important for clients with COPD who may already have compromised respiratory function.
Choice C reason: Opening the suction and tracheostomy kits is necessary for the procedure, but it should be done after ensuring the client is adequately oxygenated. Preparing the equipment is important, but patient safety and oxygenation take precedence.
Choice D reason: Suctioning the client using aseptic technique is a critical part of tracheostomy care to maintain a patent airway and prevent infection. However, this should be done after the client has been hyper-oxygenated to ensure they are stable and to minimize the risk of hypoxia during the procedure.
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