A nurse is demonstrating to a client how to perform diaphragmatic breathing. The nurse should educate the client to complete which action?

Raise both shoulders while breathing deeply.

Inhale through the mouth.

Exhale through the nose.

Tighten the abdominal muscles while exhaling.

Answer and Explanation

The Correct Answer is D

The correct answer is d) Tighten the abdominal muscles while exhaling.

Choice A Reason:

“Raise both shoulders while breathing deeply” is incorrect. Diaphragmatic breathing focuses on using the diaphragm rather than the shoulders. Raising the shoulders can lead to shallow chest breathing, which is less effective for oxygen exchange.

Choice B Reason:

“Inhale through the mouth” is incorrect. For diaphragmatic breathing, it is recommended to inhale through the nose. This helps filter, warm, and humidify the air before it reaches the lungs.

Choice C Reason:

“Exhale through the nose” is incorrect. While exhaling through the nose is beneficial in some breathing exercises, diaphragmatic breathing typically involves exhaling through pursed lips. This technique helps slow down the exhalation and keeps the airways open longer.

Choice D Reason:

“Tighten the abdominal muscles while exhaling” is correct. Tightening the abdominal muscles helps push the diaphragm up, forcing air out of the lungs more efficiently. This action is a key component of effective diaphragmatic breathing.

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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.

A. Promotes the flow of secretions to the base of the lungs. B. Eliminates the need to cough. C. Helps clear the airways of excessive secretions. D. Limits the production of bronchial mucus.

Correct Answer is C

Explanation

Choice A reason: While chest physiotherapy can help mobilize secretions, it does not specifically promote the flow of secretions to the base of the lungs. The primary goal is to loosen and mobilize secretions so they can be coughed up and cleared from the airways. This helps improve overall lung function and oxygenation.

Choice B reason: Chest physiotherapy does not eliminate the need to cough. In fact, coughing is an essential part of the process as it helps expel the loosened secretions from the airways. The therapy aims to make coughing more effective by loosening the mucus.

Choice C reason: The primary purpose of chest physiotherapy with percussion and vibration is to help clear the airways of excessive secretions. This is particularly important for patients with conditions like chronic obstructive pulmonary disease (COPD), cystic fibrosis, or pneumonia, where mucus buildup can obstruct the airways and impair breathing. By loosening and mobilizing the secretions, the therapy facilitates their removal through coughing.

Choice D reason: Chest physiotherapy does not limit the production of bronchial mucus. It focuses on clearing existing mucus from the airways rather than reducing its production. The production of mucus is influenced by underlying conditions and may require other treatments to manage.

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A nurse is demonstrating to a client how to perform diaphragmatic breathing. The nurse should educate the client to complete which action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is rounding on a client with bilateral wrist restraints. Which finding would warrant the nurse to loosen the restraints?

Correct Answer is C

Explanation

A primary health care provider orders chest physiotherapy with percussion and vibration for a client. After the health care provider leaves, the client says, “I still don’t understand the purpose of this therapy.” Which statement should be included in the nurse’s response?

Correct Answer is C

Explanation

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