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 ["B","C","D"]
Explanation
Choice A Reason:
Administering 0.45% NS (normal saline) at 50 mL/h is not appropriate for a client with SIADH (Syndrome of Inappropriate Antidiuretic Hormone Secretion). This solution is hypotonic and can exacerbate the condition by increasing water retention and worsening hyponatremia. Therefore, this choice is not included in the plan of care.
Choice B Reason:
Obtaining daily weight is crucial for monitoring fluid balance in clients with SIADH. Daily weights help detect fluid retention or loss, which is essential for managing the condition. Accurate weight measurements can indicate changes in fluid status and guide adjustments in treatment.
Choice C Reason:
Maintaining seizure precautions is vital for clients with SIADH because severe hyponatremia can lead to neurological symptoms, including seizures. Implementing seizure precautions helps ensure the client’s safety and allows for prompt intervention if seizures occur.
Choice D Reason:
Administering 3% saline as ordered is appropriate for treating severe hyponatremia in clients with SIADH. Hypertonic saline helps increase serum sodium levels, which is critical for correcting the electrolyte imbalance. This intervention should be closely monitored to avoid rapid changes in sodium levels.
Choice E Reason:
Encouraging fluid intake is not appropriate for clients with SIADH. The condition is characterized by excessive water retention, and increasing fluid intake can worsen hyponatremia. Instead, fluid restriction is typically recommended to manage the condition effectively.
Correct Answer is J
Explanation
Choice A Reason:
Gaining weight can be an indicator of improved nutrition, but it does not directly address the client’s ability to swallow safely and effectively. Weight gain could be due to other factors such as fluid retention or changes in metabolism. Therefore, while it is a positive outcome, it is not the best indicator of improved swallowing function.
Choice B Reason:
Choosing preferred items from the menu indicates that the client is engaged in their meal planning and has an appetite. However, it does not directly measure the client’s ability to swallow safely. The client might still have difficulty swallowing even if they are choosing their preferred foods.
Choice C Reason:
Clear understanding and articulation are important for communication and can indicate cognitive improvement. However, this choice does not directly relate to the client’s swallowing ability. The primary concern in this scenario is the client’s ability to swallow safely, not their communication skills.
Choice D Reason:
Eating 75 to 100% of all meals and snacks is the best indicator that the client has improved their swallowing ability. This choice directly measures the client’s ability to consume food and liquids safely and effectively. It shows that the client can manage their meals without significant difficulty, which is the primary goal of the intervention.
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