A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with emphysema.
Which of the following instructions should be included in the teaching?
Limit fluid intake throughout the day.
Breathe in through her nose and out through pursed lips.
Consume a low-protein diet.
Rest in a supine position.
The Correct Answer is B
Choice A rationale:
Limiting fluid intake throughout the day is not a suitable instruction for a client diagnosed with emphysema. Emphysema is a chronic obstructive pulmonary disease (COPD), and adequate hydration is important for individuals with this condition. Dehydration can lead to thicker mucus in the airways, making it harder to breathe. Clients with emphysema should be encouraged to maintain proper hydration.
Choice B rationale:
Instructing the client to breathe in through her nose and out through pursed lips is a beneficial technique for improving gas exchange in emphysema. This breathing technique, known as pursed-lip breathing, helps slow down the exhalation and maintains positive pressure in the airways, which can prevent airway collapse. It also promotes better oxygen exchange and reduces the feeling of breathlessness.
Choice C rationale:
Consuming a low-protein diet is not advisable for a client with emphysema. Protein is essential for tissue repair and overall health. Clients with emphysema should follow a balanced diet to maintain their energy levels and support their respiratory function. Restricting protein intake is not a standard recommendation for managing emphysema.
Choice D rationale:
Instructing the client to rest in a supine position is not a suitable recommendation. Emphysema clients often find it easier to breathe when in an upright or semi-Fowler's position, as it allows for better lung expansion and oxygen exchange. Resting in a supine position can compromise their ability to breathe effectively and may worsen their symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Skipping coffee on the morning of the exercise ECG stress test is a good idea as caffeine can affect heart rate and blood pressure, but it doesn't necessarily indicate the need for further instructions.
Choice B rationale:
Getting 8 hours of sleep the night before the test is a positive choice and promotes overall well-being, but it is not a specific indicator of needing further instructions for the test.
Choice C rationale:
Not smoking before the test is an appropriate action, as smoking can also affect heart rate and blood pressure during the test. However, it does not indicate a need for further instructions.
Choice D rationale:
Expecting to feel chest pain during an exercise ECG stress test is not correct and indicates a need for further instructions. Chest pain during the test can be a sign of cardiovascular issues and should be reported immediately.
Correct Answer is A
Explanation
Choice A rationale:
The client's arterial blood gas (ABG) results indicate a low pH (acidemia) and high PaCO2, which is characteristic of respiratory acidosis. Respiratory acidosis occurs when there is inadequate removal of carbon dioxide (CO2) from the body, leading to an accumulation of CO2 and a decrease in pH. In this case, the high PaCO2 (50 mm Hg) indicates that the client is retaining carbon dioxide, likely due to impaired ventilation. The normal pH range is 7.35 to 7.45, and the normal PaCO2 range is 35 to 45 mm Hg. These ABG values reflect an acid-base imbalance in the respiratory system, specifically, respiratory acidosis.
Choice B rationale:
Metabolic alkalosis is characterized by an elevated pH and an increase in bicarbonate (HCO3) levels. This is not the condition described in the client's ABG results, as the pH is low (acidemic) and HCO3 levels are within the normal range (24 mEq/L).
Choice C rationale:
Metabolic acidosis is characterized by a low pH and a decreased HCO3 level. The client's ABG results do not align with metabolic acidosis since the pH is low (acidemic) and the HCO3 level is within the normal range (24 mEq/L).
Choice D rationale:
Respiratory alkalosis is characterized by a high pH and low PaCO2. The client's ABG results do not match this condition as the pH is low (acidemic) and the PaCO2 is high (50 mm Hg), indicating respiratory acidosis. Therefore, choice A, respiratory acidosis, is the correct interpretation of the ABG results.
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