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 C
Explanation
Choice A rationale:
Administer IV morphine. Administering IV morphine may be necessary for pain management in a client with a pulmonary embolism. However, pain relief should not take precedence over ensuring the patient's oxygenation and cardiovascular stability. Oxygen therapy is the top priority to address hypoxia and prevent further deterioration. Once oxygenation is secured, pain management can be considered.
Choice B rationale:
Start an IV infusion of lactated Ringer's. Initiating an IV infusion of lactated Ringer's solution may be important for maintaining hydration and electrolyte balance in a patient with a pulmonary embolism. However, this is not the top priority when a client is at risk of or experiencing a pulmonary embolism. Ensuring oxygenation and cardiovascular stability takes precedence. Once the patient is stable, intravenous fluids can be administered if needed.
Choice D rationale:
Initiate cardiac monitoring. Initiating cardiac monitoring is important in assessing the patient's cardiac rhythm and identifying any dysrhythmias or changes that may occur due to the pulmonary embolism. While this is a vital step, it is not the highest priority when the client is in a state of hypoxia and respiratory distress. Oxygen therapy should be the first intervention to address the immediate threat to the patient's life.
Correct Answer is B
Explanation
Choice A rationale:
Checking the client's blood pressure is not the priority action when administering digoxin. Although monitoring blood pressure is essential in the overall care of a client with heart failure, the most critical parameter to assess before administering digoxin is the client's apical pulse.
Choice B rationale:
Measuring the client's apical pulse is the correct action to take before administering digoxin. Digoxin is a medication commonly prescribed for heart failure, and it has a narrow therapeutic range. It primarily works by increasing the force of the heart's contractions, and an excessively low heart rate (bradycardia) is a potential side effect of digoxin. Therefore, it is crucial to assess the client's apical pulse to ensure it is within the recommended range (usually above 60 beats per minute) before administering the medication. If the pulse rate is below the recommended range, the nurse should withhold the digoxin and notify the healthcare provider.
Choice C rationale:
Offering the client a light snack is not a necessary action before administering digoxin. While it is important to consider the client's dietary needs, it is not directly related to the administration of digoxin. However, if the client has nausea or vomiting, which can be a side effect of digoxin, a light snack might be offered after the medication.
Choice D rationale:
Weighing the client is not the immediate action to take before administering digoxin. Although daily weights can be important for assessing fluid balance in clients with heart failure, it is not the priority before administering digoxin. Monitoring the client's apical pulse is the most critical step in this context.
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