A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). The nurse positions the client in the orthopneic position. What is the primary reason for the use of this position for this client?
Prevents pressure ulcers.
Supports hip extension.
Facilitates breathing.
Promotes urinary elimination.
The Correct Answer is C
Choice A Reason:
“Prevents pressure ulcers” is incorrect. While positioning can help prevent pressure ulcers, the orthopneic position is specifically used to aid in breathing rather than to prevent pressure ulcers. Pressure ulcers are typically managed by regularly repositioning the client and using pressure-relieving devices.
Choice B Reason:
“Supports hip extension” is incorrect. The orthopneic position does not primarily support hip extension. This position involves sitting up and leaning forward, which does not significantly affect the hips.
Choice C Reason:
“Facilitates breathing” is correct. The orthopneic position, also known as the tripod position, helps to improve breathing in clients with COPD. By leaning forward and resting the arms on a table or knees, the diaphragm can move more freely, and accessory muscles of respiration are better utilized, reducing the work of breathing.
Choice D Reason:
“Promotes urinary elimination” is incorrect. The orthopneic position is not intended to promote urinary elimination. Urinary elimination is typically managed through other interventions such as ensuring adequate hydration and, if necessary, using a catheter.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The glossopharyngeal nerve (CN IX) is primarily responsible for the gag reflex. It provides sensory input from the pharynx and posterior third of the tongue, which triggers the gag reflex when stimulated. This nerve plays a crucial role in swallowing and the reflexive action to prevent choking.
Choice B reason: The trigeminal nerve (CN V) is responsible for facial sensation and motor functions such as biting and chewing. It does not play a direct role in the gag reflex. While it is important for other sensory and motor functions, it is not involved in the reflex being assessed here.
Choice C reason: The vagus nerve (CN X) also contributes to the gag reflex by providing motor innervation to the muscles of the pharynx and larynx. However, the primary sensory input for the gag reflex comes from the glossopharyngeal nerve (CN IX). The vagus nerve works in conjunction with CN IX to complete the reflex action.
Choice D reason: The hypoglossal nerve (CN XII) controls the movements of the tongue. It is essential for speech and swallowing but does not have a role in the gag reflex. The hypoglossal nerve’s primary function is motor control of the tongue muscles.
Correct Answer is C
Explanation
Choice A Reason:
The client has full range of motion in her wrist does not necessarily indicate a need to loosen the restraints. Full range of motion suggests that the restraints are not too tight and are allowing for some movement. However, it is important to regularly assess the client’s circulation, skin integrity, and comfort to ensure the restraints are not causing harm.
Choice B Reason:
The client is attempting to remove the restraint is a common behavior in clients who are restrained, especially if they are confused or agitated. While this behavior warrants close monitoring and possibly re-evaluating the need for restraints, it does not necessarily indicate that the restraints need to be loosened. The nurse should assess the client’s overall condition and consider alternative methods to ensure safety.
Choice C Reason:
The client has cyanotic digits is a critical finding that indicates impaired circulation. Cyanosis, or a bluish discoloration of the skin, occurs when there is a lack of oxygen in the blood. This can be a sign that the restraints are too tight and are restricting blood flow to the extremities. In this case, the nurse should immediately loosen the restraints to restore proper circulation and prevent further complications.
Choice D Reason:
The client denies discomfort is a positive finding, indicating that the client is not experiencing pain or distress from the restraints. However, the absence of discomfort does not rule out other potential issues such as impaired circulation or skin breakdown. Regular assessments are necessary to ensure the restraints are being used safely and effectively.
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