A nurse is teaching a client who has COPD about purse-lipped breathing. Which of the following statements should the nurse make?
"You should be flat on your back when you perform purse-lipped breathing"
"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"
The Correct Answer is B
A. Pursed-lip breathing does not require a specific body position, but it is often more comfortable and effective when the patient is in a semi-Fowler’s position (elevated head of the bed) or sitting upright. Being flat on the back might actually make breathing more difficult for some patients with COPD.
B. The technique involves inhaling slowly through the nose and exhaling through pursed lips, which creates a slight resistance during expiration. This helps to keep the airways open longer, reduce airway collapse, and improve oxygen exchange. Proper inhalation and exhalation technique are key components of effective pursed-lip breathing.
C. In pursed-lip breathing, expiration should be longer than inspiration. The recommended pattern is to inhale slowly through the nose for about 2 counts and then exhale slowly through pursed lips for about 4 counts. The extended expiration phase helps to remove trapped air from the lungs and improves overall ventilation.
D. Coughing forcefully is not a part of pursed-lip breathing. Pursed-lip breathing focuses on controlled breathing to improve airflow and ease breathing. Coughing can be done separately if needed, but it is not a component of the pursed-lip breathing technique.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While administering 0.9% sodium chloride is an important step to maintain venous access and to help dilute any blood that might still be in the tubing, it is not the first action to take if a transfusion reaction is suspected. This step should occur after the transfusion is stopped and the patient’s safety is ensured.
B. The immediate priority when a transfusion reaction is suspected is to stop the transfusion immediately. This action helps to prevent further exposure to the potentially harmful blood product and mitigates the risk of worsening the reaction. Stopping the transfusion also allows for prompt medical assessment and intervention.
C. Returning the unit of blood to the blood bank is important for investigation and to determine the cause of the reaction, but it should be done after stopping the transfusion and ensuring the client’s safety. The blood bank may require the returned unit to confirm any issues with the blood product.
D. Obtaining a blood sample from the client is crucial for diagnostic purposes and to identify the cause of the reaction, but this should be done after the transfusion has been stopped. The sample may help in diagnosing the type of reaction or in managing it, but it does not address the immediate safety concerns.
Correct Answer is B
Explanation
A. Abdominal pain is not a direct manifestation of respiratory acidosis. However, it may be associated with other conditions or complications but is not a primary indicator of respiratory acidosis.
B. Lethargy or drowsiness is a common symptom of respiratory acidosis. The increased CO₂ levels lead to an acidic environment that can affect brain function, resulting in decreased alertness, confusion, or drowsiness.
C. Numbness or tingling of the fingers is more commonly associated with respiratory alkalosis, which is characterized by a decreased level of CO₂ and increased blood pH. This condition can cause peripheral numbness and tingling due to altered blood pH affecting nerve function.
D. Dry skin is not a direct manifestation of respiratory acidosis. While it might be a sign of dehydration or other systemic issues, it is not specifically linked to respiratory acidosis.
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