A nurse is reinforcing teaching about self-management strategies with a client who has emphysema.
Which of the following client statements indicates that the client understands the instructions?
"I will drink about 34 ounces of fluid every day.”.
"I will inhale slowly through pursed lips to help me breathe better.”.
"I will follow a diet high in calories and protein.”.
"I will lie on my stomach to practice abdominal breathing every day.”. .
The Correct Answer is C
The correct answer is choice C: “I will follow a diet high in calories and protein.”
Here are the rationales for each choice:
Choice A rationale: “I will drink about 34 ounces of fluid every day.” While staying hydrated is important for overall health, this statement does not specifically address a key self-management strategy for emphysema. Adequate fluid intake can help thin mucus, making it easier to expel, but it is not the most critical aspect of managing emphysema.
Choice B rationale: “I will inhale slowly through pursed lips to help me breathe better.” This statement is incorrect because the correct technique is to exhale through pursed lips, not inhale. Pursed-lip breathing helps to keep the airways open longer, reduce shortness of breath, and improve the exchange of oxygen and carbon dioxide.
Choice C rationale: “I will follow a diet high in calories and protein.” This is the correct answer. Emphysema can increase the body’s energy expenditure due to the effort required for breathing. A diet high in calories and protein helps maintain muscle mass and provides the necessary energy to support respiratory function.
Choice D rationale: “I will lie on my stomach to practice abdominal breathing every day.” This statement is not recommended for emphysema management. While abdominal or diaphragmatic breathing can be beneficial, lying on the stomach is not a typical position for practicing this technique. It is usually done while sitting or lying on the back.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Hypovolemic shock is characterized by a decrease in blood volume, leading to low blood pressure and compensatory mechanisms such as a high pulse rate. When the body experiences a significant loss of blood or fluid, it attempts to maintain perfusion to vital organs by increasing the heart rate to ensure an adequate blood supply. Low blood pressure and a high pulse rate are classic signs of hypovolemic shock.
Choice B rationale:
A low BP and low pulse rate are not indicative of hypovolemic shock. Hypovolemic shock is associated with a rapid and weak pulse rate as the body tries to compensate for decreased blood volume. A low pulse rate could suggest other conditions, such as bradycardia, rather than hypovolemic shock.
Choice C rationale:
High BP and high pulse rate are not typical findings in hypovolemic shock. Hypovolemic shock is characterized by low blood pressure and a high pulse rate as the body attempts to compensate for the reduced blood volume. High blood pressure is more commonly associated with conditions like hypertension, not hypovolemic shock.
Choice D rationale:
High BP and low pulse rate are not consistent with the characteristics of hypovolemic shock. As mentioned earlier, hypovolemic shock is marked by low blood pressure and a high pulse rate due to the body's efforts to maintain adequate perfusion. High blood pressure and a low pulse rate may suggest other medical conditions unrelated to hypovolemic shock.
Correct Answer is A
Explanation
The correct answer is choiceA. Heart rate 50/min.
Choice A rationale:
Atenolol is a beta-blocker that can significantly lower heart rate.A heart rate of 50/min is considered bradycardia (slow heart rate), and administering atenolol could further decrease the heart rate to a dangerously low level. Therefore, the nurse should withhold the medication in this case.
Choice B rationale:
A respiratory rate of 18/min is within the normal range (12-20 breaths per minute) and does not contraindicate the use of atenolol. Therefore, this finding would not require withholding the medication.
Choice C rationale:
An oxygen saturation of 95% is within the normal range (typically 95-100%) and does not contraindicate the use of atenolol. Thus, this finding would not necessitate withholding the medication.
Choice D rationale:
While a blood pressure of 160/94 mm Hg indicates hypertension, atenolol is often prescribed to manage high blood pressure. Therefore, this finding would not require withholding the medication.
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