A nurse is reinforcing teaching with a client who has COPD about purse-lipped breathing. Which of the following statements should the nurse make?
"You should inhale through your nose and exhale through your mouth during purse-lipped breathing."
"Your inspiration should be longer than expiration during purse-lipped breathing."
"You should cough forcefully during exhalation when you are purse-lipped breathing."
"You should be flat on your back when you perform purse-lipped breathing."
The Correct Answer is A
A. "You should inhale through your nose and exhale through your mouth during purse-lipped breathing."
Pursed-lip breathing is a breathing technique commonly used by individuals with COPD to help improve breathing efficiency and manage dyspnea (shortness of breath). During purse-lip breathing, the individual inhales slowly through the nose and exhales slowly and gently through pursed lips, creating a slight resistance to the airflow. This technique helps to keep the airways open longer during exhalation, reduces air trapping, and improves oxygenation.
B. "Your inspiration should be longer than expiration during purse-lipped breathing."
Pursed-lip breathing typically involves making both the inspiration and expiration longer than usual. The focus is on slowing down the breathing rate and extending the exhalation phase to promote better gas exchange and reduce respiratory effort.
C. "You should cough forcefully during exhalation when you are purse-lipped breathing."
Pursed-lip breathing is a gentle breathing technique used to promote relaxation and control of breathing. Forceful coughing during exhalation is not part of purse-lip breathing and may not be appropriate, especially for individuals with COPD who are prone to airway irritation and bronchospasm.
D. "You should be flat on your back when you perform purse-lipped breathing."
The position for performing purse-lip breathing is not specific to lying flat on the back. Individuals can perform purse-lip breathing in various positions that are comfortable and allow for effective breathing, such as sitting upright or leaning slightly forward. The key is to find a position that facilitates relaxation and optimal lung expansion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Provide humidified oxygen.
Humidified oxygen adds moisture to the air, which can help to thin secretions in the airway. Thinning the secretions makes them easier to clear, particularly for patients with copious and tenacious secretions, such as those following a tracheostomy.
B. Perform chest physiotherapy prior to suctioning.
Chest physiotherapy techniques, such as percussion and vibration, can help to mobilize secretions in the lungs and airways. While this may indirectly assist in clearing secretions, it does not directly address the issue of thinning the secretions, which is the primary concern in this scenario.
C. Prelubricate the suction catheter tip with sterile saline when suctioning the airway.
Prelubricating the suction catheter tip with sterile saline before suctioning can help reduce friction and potential trauma to the airway. While this can be beneficial for airway management, it does not directly address the need to thin copious and tenacious secretions.
D. Hyperventilate the client with 100% oxygen before suctioning the airway.
Hyperventilating the client with 100% oxygen before suctioning is not recommended. It can lead to respiratory alkalosis, which is a condition characterized by decreased levels of carbon dioxide in the blood. This can worsen the client's condition and may lead to adverse effects. Additionally, it does not directly address the need to thin secretions.
Correct Answer is A
Explanation
A. Lower oxygen saturations of 93% to 94%
In an older adult client with a pneumothorax, the nurse could expect to observe lower oxygen saturations of 93% to 94%. A pneumothorax involves the accumulation of air in the pleural space, which can compress the lung and impair gas exchange, leading to hypoxemia (low blood oxygen levels). Decreased oxygen saturations would be a common finding in this condition.
B. Higher oxygen saturations of 98% to 99%
Higher oxygen saturations would be less likely in a client with a pneumothorax due to impaired gas exchange resulting from lung compression. Oxygen saturations are more likely to be lower in this condition, as indicated in option A.
C. Lower energy expenditure
While a pneumothorax may cause discomfort and dyspnea, which could potentially decrease energy expenditure due to reduced activity levels, it is not a direct physiological effect of the condition. Energy expenditure would depend on various factors, including the severity of symptoms and the individual's overall health status.
D. Increased lung capacity
A pneumothorax typically results in a decrease in lung capacity rather than an increase. The accumulation of air in the pleural space causes partial or complete collapse of the affected lung, reducing its ability to expand and decreasing overall lung capacity. Therefore, increased lung capacity would not be expected in a client with a pneumothorax.
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