A nurse is teaching pursed-lip breathing to a client who has COPD. Which of the following instructions should the nurse include in the teaching?
"Lie down while practicing pursed-lip breathing.".
"Exhale slowly through your mouth.".
"Inhale through pursed lips.".
"Puff your cheeks when exhaling.".
The Correct Answer is B
Choice A rationale:
Lying down while practicing pursed-lip breathing is not the correct instruction. Pursed-lip breathing is usually performed in a sitting or standing position. Lying down can restrict lung expansion and may not effectively support the purpose of this breathing technique, which is to improve airway pressure and reduce air trapping.
Choice B rationale:
"Exhale slowly through your mouth" is the correct instruction for pursed-lip breathing. This technique involves inhaling through the nose for a count of two and exhaling slowly and steadily through pursed lips for a count of four. The goal is to promote better exhalation, prevent airway collapse, and improve oxygen exchange. The rationale behind this choice is grounded in the mechanics of pursed-lip breathing, which helps create backpressure in the airways, maintaining them open and aiding in proper exhalation.
Choice C rationale:
Inhaling through pursed lips contradicts the proper sequence of pursed-lip breathing. The technique involves inhaling through the nose and exhaling through pursed lips. Inhaling through pursed lips would not provide the intended benefits of the technique.
Choice D rationale:
"Puff your cheeks when exhaling" is not the correct instruction. Puffing the cheeks during exhalation does not contribute to the effectiveness of pursed-lip breathing. This action could potentially impede proper exhalation and defeat the purpose of the technique, which is to control airflow and improve breathing efficiency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Justice refers to the fair distribution of resources and benefits. It pertains to treating individuals equitably and ensuring that their rights are respected. However, in this scenario, the nurse is specifically addressing the client's right to refuse treatment, which aligns more with the concept of autonomy.
Choice B rationale:
Veracity is the principle of truthfulness and honesty in communication between healthcare professionals and clients. While it is an important ethical principle, it does not directly relate to the client's right to refuse treatment. This right falls under the principle of autonomy, where individuals have the right to make decisions about their own healthcare, including the decision to refuse treatment.
Choice C rationale:
Fidelity, also known as loyalty or faithfulness, refers to the nurse's commitment to keeping promises and being dedicated to the well-being of the client. While respecting the client's autonomy is part of being faithful to their needs and preferences, the specific right to refuse treatment is better categorized under the principle of autonomy.
Choice D rationale:
Autonomy is the correct choice. Autonomy emphasizes an individual's right to make decisions regarding their own healthcare based on their values, beliefs, and preferences. In this context, the nurse's responsibility is to uphold the client's autonomy by respecting their decision to refuse treatment. The nurse should ensure that the client has been properly informed about the risks and benefits of the treatment and that their decision is voluntary and informed.
Correct Answer is D
Explanation
Choice A rationale:
Using a 5-mL syringe to flush the catheter is not the best choice. Central venous access devices typically require a larger syringe for flushing to prevent excessive pressure and potential damage to the catheter. A smaller syringe like the 5-mL syringe can create higher pressure, which could cause complications.
Choice B rationale:
Changing the site dressing and stabilization device every 24 hours is not the recommended practice. The dressing and stabilization device should be changed according to facility policy and as needed, but a rigid 24-hour schedule is not necessary and might increase the risk of infection due to unnecessary exposure.
Choice C rationale:
Expecting blood to appear in the catheter lumen after flushing is incorrect. Blood in the catheter lumen after flushing could indicate complications such as a dislodged catheter or other issues requiring immediate attention. The catheter should ideally remain patent without the presence of blood.
Choice D rationale:
This is the correct choice. Using chlorhexidine solution to clean the catheter is an evidence-based practice to prevent infection at the insertion site. Chlorhexidine has broad-spectrum antimicrobial properties and helps reduce the risk of catheter-related infections.
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