The practical nurse (PN) reinforces client teaching in performing pursed lip breathing. The client returns the demonstration, as seen in the image. Which action should the PN take after observing this return demonstration?
Confirm that the client is using the correct technique.
Review each step of the breathing technique with the client.
Demonstrate how to breathe in more slowly and effectively.
Remind the client to cough deeply to loosen secretions.
The Correct Answer is A
A. Confirm that the client is using the correct technique: Observing a return demonstration allows the PN to verify that the client can perform pursed-lip breathing correctly. Confirming proper technique ensures the client can use this method effectively to improve ventilation and control dyspnea.
B. Review each step of the breathing technique with the client: Reviewing steps is appropriate if the client demonstrates errors or uncertainty. If the demonstration is correct, repeated review is unnecessary and may not add value.
C. Demonstrate how to breathe in more slowly and effectively: Additional demonstration is only needed if the client’s technique is incorrect or inefficient. Unneeded repetition may cause confusion when the client is already performing correctly.
D. Remind the client to cough deeply to loosen secretions: While coughing can help clear secretions, it is not part of pursed-lip breathing instruction. Introducing unrelated techniques may distract from mastering the intended breathing method.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Assist with ambulation several times a day: Ambulation promotes venous return and helps reduce dependent edema in the ankles. Encouraging movement is the most direct and effective intervention to manage edema when there are no underlying cardiac or renal problems.
B. Provide low protein snacks between meals: Dietary protein restriction is not indicated for mild, dependent edema in a healthy client. Low protein intake would not reduce edema and may negatively affect nutritional status.
C. Remind the client to sit upright while awake: Sitting upright can prevent respiratory complications and promote comfort, but it has minimal effect on ankle edema, which is influenced more by activity and circulation.
D. Encourage a regular toileting schedule: Maintaining a toileting schedule supports continence and comfort but does not directly impact the management of peripheral edema.
Correct Answer is A
Explanation
A. Inspection: Jugular vein distention is assessed visually with the client positioned at a 30–45° angle. Observation of the jugular veins provides information about central venous pressure and fluid status.
B. Palpation: Palpating the jugular vein is not recommended because it can cause discomfort and may collapse the vein, making assessment inaccurate. Visual inspection is preferred.
C. Auscultation: Listening with a stethoscope is not used to assess JVD. Auscultation is more appropriate for evaluating heart or lung sounds rather than vein distention.
D. Percussion: Percussion is not effective for assessing jugular vein distention. This technique is used to evaluate underlying structures in the chest or abdomen, not superficial vein distention.
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