The nurse observes an adult client perform a return demonstration of diaphragmatic breathing. The client inhales while holding the abdomen, then removes the hand to allow expansion of the abdomen during exhalation. Which action should the nurse take after observing the client’s demonstration?

Remind the client to keep light pressure on the abdomen and cough after fully exhaling.

Confirm that the breathing technique was correct but hand pressure is not necessary.

Document that the client successfully demonstrated the diaphragmatic breathing technique.

Demonstrate how to expand the abdomen while inhaling and let it relax while exhaling.

Answer and Explanation

The Correct Answer is D

Choice A reason: Keeping pressure on the abdomen and coughing is incorrect for diaphragmatic breathing, which enhances lung expansion, not airway clearance. Coughing is for post-drainage. The client’s incorrect technique (abdominal expansion on exhalation) requires correction, as this reverses mechanics, reducing ventilation efficiency in conditions like COPD.

Choice B reason: The client’s technique is incorrect, expanding the abdomen on exhalation, not inhalation, reducing diaphragmatic efficacy. Confirming it as correct is wrong, as it impairs lung expansion. Demonstrating proper technique corrects the error, ensuring effective breathing to improve oxygenation, addressing the physiological need for ventilation.

Choice C reason: Documenting success is inaccurate, as the client’s technique is reversed, expanding the abdomen on exhalation. Diaphragmatic breathing requires inhalation expansion to lower the diaphragm, increasing lung capacity. Correcting the technique via demonstration ensures proper mechanics, not documenting an ineffective method that hinders ventilation.

Choice D reason: Demonstrating proper diaphragmatic breathing corrects the client’s error of exhalation expansion. Inhaling expands the abdomen via diaphragmatic descent, increasing tidal volume; exhaling relaxes it. This optimizes ventilation, addressing the need for effective breathing in conditions requiring enhanced lung function, ensuring the client learns the correct technique.

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Correct Answer is B

Explanation

Choice A reason: Administering oxygen supports oxygenation but is not the priority during a seizure, typically brief without sustained hypoxia. Removing objects prevents trauma from tonic-clonic movements, driven by neuronal hyperexcitability, addressing the immediate risk of fractures or head injuries during uncontrolled muscle activity.

Choice B reason: Removing objects prevents injury during a seizure, as tonic-clonic convulsions from excessive neuronal discharges risk trauma like fractures. Ensuring a safe environment addresses the physiological risk of harm from environmental hazards, critical for protecting the client during uncontrolled movements in seizure activity.

Choice C reason: Placing pillows around the head may reduce injury but is less effective than clearing hazards, as seizures involve full-body movements. Pillows may not stay secure during clonic jerking. Removing objects ensures broader safety, minimizing trauma risk across all body areas, making this less immediate.

Choice D reason: Applying restraints is contraindicated, as they risk injury like fractures by resisting forceful neuronal-driven movements. Seizures require safe movement in a clear environment. Removing objects prevents trauma, addressing the physiological need for safety during a seizure, making restraints inappropriate and potentially harmful.

A. Change the tracheostomy ties every 48 hours. B. Suction the tracheostomy every 2 hours routinely. C. Assess airway patency every shift. D. Clean the inner cannula with hydrogen peroxide daily.

Correct Answer is C

Explanation

Choice A reason: Changing tracheostomy ties every 48 hours maintains hygiene but is less critical than airway patency. Ties secure the tube, but obstruction from mucus or dislodgement risks respiratory failure. Regular patency checks ensure airflow, addressing the primary physiological need for oxygenation in tracheostomy care.

Choice B reason: Routine suctioning every 2 hours is unnecessary unless secretions obstruct the airway. Over-suctioning risks mucosal trauma or hypoxia. Assessing patency ensures the airway remains clear, guiding suctioning as needed, prioritizing respiratory function in tracheostomy clients over arbitrary suction schedules.

Choice C reason: Assessing airway patency every shift is critical, as tracheostomy tubes risk obstruction from mucus or dislodgement, causing respiratory distress. Regular checks confirm airflow, preventing hypoxia, addressing the physiological priority of oxygenation. This ensures timely intervention, maintaining airway integrity in clients with artificial airways.

Choice D reason: Cleaning the inner cannula daily prevents infection but is secondary to airway patency. Obstruction from secretions or tube displacement causes immediate respiratory failure. Patency assessment ensures airflow, guiding cleaning as needed, making it more urgent than routine cannula maintenance in tracheostomy care.

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The nurse observes an adult client perform a return demonstration of diaphragmatic breathing. The client inhales while holding the abdomen, then removes the hand to allow expansion of the abdomen during exhalation. Which action should the nurse take after observing the client’s demonstration?

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After placing a client who is having a seizure in the side-lying position, which intervention should the nurse implement?

Correct Answer is B

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The nurse is caring for a client with a new tracheostomy. Which action is most important to include in the client’s plan of care?

Correct Answer is C

Explanation

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