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 C
Explanation
The correct answer is choiceC. “I’ll compare the sensations I feel when I tense my muscles to what I feel when I relax them.”
Choice A rationale:While breathing normally is important during relaxation techniques, progressive muscle relaxation specifically focuses on tensing and relaxing muscle groups to recognize the difference in sensations.
Choice B rationale:Imagining a peaceful setting is more related to guided imagery or visualization techniques, not progressive muscle relaxation.
Choice C rationale:This is correct because progressive muscle relaxation involves tensing and then relaxing muscle groups to help the individual recognize the difference between tension and relaxation.
Choice D rationale:Using a series of stretches is not a part of progressive muscle relaxation; it is more related to stretching exercises or yoga.
Correct Answer is D
Explanation
The correct answer is choice d. When removing a peripheral IV catheter, the nurse uses scissors to remove the tape that secures the catheter.
Choice A rationale:
Inserting the tip of the enema tube 8 cm (3.1 in) is within the recommended range for adults, which is typically 7.5 to 10 cm (3 to 4 in). This action does not require intervention.
Choice B rationale:
Elevating the head of the bed when caring for a client’s body after death is a standard practice to prevent discoloration of the face and to facilitate drainage. This action does not require intervention.
Choice C rationale:
Using a clean washcloth, soap, and water for indwelling catheter care is appropriate and follows infection control guidelines. This action does not require intervention.
Choice D rationale:
Using scissors to remove the tape that secures a peripheral IV catheter is unsafe as it poses a risk of cutting the catheter or the client’s skin. This action requires intervention to ensure the nurse uses a safer method, such as using adhesive remover or gently peeling the tape away by hand.
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