A nurse is reinforcing discharge teaching about improving gas exchange with a client who has emphysema. Which of the following information should the nurse include in the teaching?
Use pursed-lip breathing during periods of dyspnea.
Limit fluid intake to 1,500 ml per day.
Practice chest breathing each day.
Wear home oxygen to maintain an SpO2 of at least 94%.
The Correct Answer is A
Choice A reason: This is the correct information, because pursed-lip breathing can help improve gas exchange by creating positive pressure in the airways, preventing air trapping and alveolar collapse, and increasing the exhalation time.
Choice B reason: This is an incorrect information, because limiting fluid intake to 1,500 ml per day can cause dehydration and thickening of the respiratory secretions, which can impair gas exchange and increase the risk of infection.
Choice C reason: This is an incorrect information, because practicing chest breathing each day can worsen gas exchange by increasing the use of accessory muscles, decreasing the diaphragmatic excursion, and reducing the lung expansion.
Choice D reason: This is an incorrect information, because wearing home oxygen to maintain an SpO2 of at least 94% can be harmful for a client who has emphysema, as it can suppress the hypoxic drive and cause carbon dioxide retention, which can lead to respiratory acidosis and coma. The client who has emphysema should wear home oxygen to maintain an SpO2 of 88% to 92%, or as prescribed by the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Irrigating the catheter with sterile water is an incorrect action, because the catheter should be irrigated with sterile normal saline (0.9% sodium chloride) to prevent hemolysis of the red blood cells.
Choice B reason: Clamping the drainage catheter during ambulation is an incorrect action, because the catheter should be kept patent and unclamped at all times to prevent obstruction and infection.
Choice C reason: Reporting viscous drainage with clots to the provider is a correct action, because it indicates that the irrigation is not effective and the client may need manual irrigation or surgical intervention.
Choice D reason: Removing the catheter if the client feels a strong urge to urinate is an incorrect action, because the catheter should be left in place until the provider orders its removal. The client may feel a sensation of bladder fullness or spasms due to the irrigation fluid, which can be relieved by medication or adjustment of the flow rate.
Correct Answer is C
Explanation
Choice A reason: Irrigating the catheter with sterile water is an incorrect action, because the catheter should be irrigated with sterile normal saline (0.9% sodium chloride) to prevent hemolysis of the red blood cells.
Choice B reason: Clamping the drainage catheter during ambulation is an incorrect action, because the catheter should be kept patent and unclamped at all times to prevent obstruction and infection.
Choice C reason: Reporting viscous drainage with clots to the provider is a correct action, because it indicates that the irrigation is not effective and the client may need manual irrigation or surgical intervention.
Choice D reason: Removing the catheter if the client feels a strong urge to urinate is an incorrect action, because the catheter should be left in place until the provider orders its removal. The client may feel a sensation of bladder fullness or spasms due to the irrigation fluid, which can be relieved by medication or adjustment of the flow rate.
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