When teaching a client how to perform pursed lip breathing, which instructions would the nurse include? (Select all that apply)
Lean on your back with your knees bent.
Use your abdominal muscles to squeeze air out of your lungs.
Breathe out slowly without puffing your cheeks.
Focus on inhaling and holding your breath as long as you can.
Exhale at least twice the amount of time it took to breathe in.
Open your mouth and breathe deeply.
Correct Answer : B,C,E
Choice A: Lean on your back with your knees bent.
Reason: This instruction is incorrect. Pursed lip breathing is typically performed in a seated position with the neck and shoulders relaxed. Lying on your back with knees bent is not a recommended position for this breathing technique.
Choice B: Use your abdominal muscles to squeeze air out of your lungs.
Reason: This instruction is correct. Using the abdominal muscles helps to expel air more effectively from the lungs, which is a key component of pursed lip breathing. This technique helps to improve ventilation and reduce the work of breathing.

Choice C: Breathe out slowly without puffing your cheeks.
Reason: This instruction is correct. Breathing out slowly through pursed lips without puffing the cheeks helps to keep the airways open longer, allowing more air to be expelled from the lungs. This technique is particularly beneficial for individuals with chronic obstructive pulmonary disease (COPD) or other respiratory conditions.
Choice D: Focus on inhaling and holding your breath as long as you can.
Reason: This instruction is incorrect. The focus of pursed lip breathing is on controlled exhalation rather than holding the breath. Inhaling should be done slowly through the nose, and exhaling should be prolonged through pursed lips.
Choice E: Exhale at least twice the amount of time it took to breathe in.
Reason: This instruction is correct. The exhalation phase should be longer than the inhalation phase, typically taking at least twice as long. This helps to improve the efficiency of breathing and reduce shortness of breath.
Choice F: Open your mouth and breathe deeply.
Reason: This instruction is incorrect. Pursed lip breathing involves breathing in through the nose and exhaling through pursed lips. Opening the mouth and breathing deeply is not part of this technique.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
Choice A Reason:
Monitoring the QT interval is crucial when administering amiodarone because this drug can prolong the QT interval, increasing the risk of torsades de pointes, a potentially life-threatening type of ventricular tachycardia. Regular monitoring helps in early detection and management of this adverse effect, ensuring patient safety.
Title: Choice B Reason:
Heart rate monitoring is essential as amiodarone can cause bradycardia (slow heart rate). Continuous monitoring allows the nurse to detect any significant changes in heart rate and take appropriate actions, such as adjusting the medication dosage or providing interventions to manage bradycardia.
Title: Choice C Reason:
Respiratory rate monitoring is necessary because amiodarone can cause pulmonary toxicity, including interstitial pneumonitis and acute respiratory distress syndrome (ARDS). By keeping track of the respiratory rate, the nurse can identify early signs of respiratory complications and intervene promptly
Title: Choice D Reason:
Heart rhythm monitoring is vital since amiodarone is used to treat arrhythmias. Continuous electrocardiogram (ECG) monitoring helps in assessing the effectiveness of the drug in controlling arrhythmias and detecting any new or worsening arrhythmias that may require immediate attention.
Title: Choice E Reason:
Monitoring urine output is important because amiodarone can affect renal function, especially in patients with pre-existing kidney conditions. Keeping track of urine output helps in assessing renal function and ensuring that the drug is not causing nephrotoxicity
Correct Answer is C
Explanation
Choice A Reason:
Weigh the client daily: While monitoring weight is important for clients with Addison’s disease, it is not the primary action to prevent an Addisonian crisis. Daily weight monitoring helps track fluid balance and detect any sudden changes that might indicate complications, but it does not directly address the hormonal imbalance that characterizes Addisonian crisis.
Choice B Reason:
Restrict food intake: Restricting food intake is not recommended for clients with Addison’s disease. Proper nutrition is crucial for maintaining energy levels and overall health. Clients with Addison’s disease need a balanced diet to manage their condition effectively. Restricting food intake could lead to malnutrition and exacerbate symptoms.
Choice C Reason:
Administer oral corticosteroids: This is the correct action. Addison’s disease is characterized by insufficient production of cortisol and aldosterone by the adrenal glands. Administering oral corticosteroids helps replace the deficient hormones and manage the symptoms of Addison’s disease. During an Addisonian crisis, immediate administration of corticosteroids is critical to prevent severe complications such as shock, coma, or even death.
Choice D Reason:
Provide a low carbohydrate diet: A low carbohydrate diet is not specifically recommended for clients with Addison’s disease. Instead, a balanced diet that includes adequate carbohydrates, proteins, and fats is essential. Carbohydrates are important for maintaining energy levels, especially since clients with Addison’s disease may experience fatigue and weakness. Restricting carbohydrates could lead to low blood sugar levels, which can be dangerous for these clients.
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