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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is ["C","D"]

Explanation

Choice A reason:

Giving a unit of packed red blood cells is not typically indicated solely for a core temperature of 97°F (36.1°C). This intervention is usually reserved for cases of significant blood loss or anemia. Hypothermia in the postoperative period is more effectively managed with warming techniques rather than blood transfusions.

Choice B reason:

Providing warm irrigation to the operative site is not a standard intervention for managing mild hypothermia postoperatively. While warm irrigation can be used intraoperatively to maintain body temperature, it is not typically used postoperatively.

Choice C reason:

Providing warmed IV fluids is an appropriate intervention for a client with a core temperature of 97°F (36.1°C). Warmed IV fluids help to increase the core body temperature and prevent further heat loss. This is a standard practice in managing mild hypothermia in postoperative patients.

Choice D reason:

Providing a warm blanket is another effective intervention for managing mild hypothermia. Warm blankets help to increase the patient’s body temperature by reducing heat loss and providing external warmth. This is a common and effective method used in postoperative care.

Choice E reason:

Giving acetaminophen per rectum is not indicated for managing hypothermia. Acetaminophen is used to reduce fever, not to increase body temperature. In this scenario, the client needs warming interventions rather than antipyretic medication.

Correct Answer is ["10"]

Explanation

125 units of insulin in 250 mL of normal saline

Step 2: Calculate the concentration of insulin per mL.

Concentration = 125 units ÷ 250 mL
Concentration = 0.5 units/mL

Step 3: Determine the required rate of insulin administration.

Ordered dose = 5 units per hour

Step 4: Calculate the IV flow rate.

Flow rate (mL/hr) = Ordered dose ÷ Concentration
Flow rate (mL/hr) = 5 units ÷ 0.5 units/mL
Flow rate (mL/hr) = 10 mL/hr

The nurse should set the IV pump to 10 mL/hr.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who has a core temperature of 97°F (36.1°C) post-op in the post-anesthesia care unit. What action(s) will the nurse take in light of this finding? (Select all that apply)

Correct Answer is ["C","D"]

Explanation

Correct Answer is ["10"]

Explanation

The priority nursing intervention for a client who has a serum sodium level of 154 mEq/L would be:

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