The nurse instructing the patient to perform forceful exhalation coughing would instruct the patient to take in:
two deep breaths, then inhale deeply again and force out the air quickly.
one deep breath and quickly exhale
one breath, hold it for 3 seconds, then forcefully exhale three times with mouth open
two breaths and force the air out quickly
The Correct Answer is A
A. Two deep breaths, then inhale deeply again and force out the air quickly: This technique helps clear mucus by mobilizing it toward the larger airways for expulsion.
B. One deep breath and quickly exhale: This method is less effective in mobilizing secretions compared to multiple preparatory breaths.
C. One breath, hold it for 3 seconds, then forcefully exhale three times with mouth open: Holding the breath promotes mucus loosening, and repeated exhalations help clear secretions. While this technique can be correct in some protocols, it is less common for "forceful" cough instructions and may not be the preferred method.
D. Two breaths and force the air out quickly: Lacks the preparatory deep breath necessary for effective secretion clearance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Milk the chest tube to dislodge any clots in the tubing that may be occluding it. Milking the chest tube is not recommended as it can create excessive negative pressure and damage lung tissue.
B) Notify the provider. This is not the first intervention. The nurse should assess the suction regulator and connections before notifying the provider.
C) Verify that the suction regulator is on. Lack of bubbling often indicates that the suction regulator is off or not functioning correctly. The nurse should first ensure that the regulator is turned on and properly connected.
D) Continue to monitor the client because this is an expected finding. Bubbling should be present in the suction control chamber if suction is applied; therefore, this finding requires immediate assessment.
Correct Answer is A
Explanation
A. Jaundiced: The yellow discoloration of the skin can interfere with light absorption, affecting the accuracy of the reading.
B. Febrile: An elevated body temperature does not affect the pulse oximeter's accuracy.
C. Obese: Subcutaneous fat does not interfere with the device's light absorption or reading accuracy.
D. Dark-skinned: Higher melanin levels can affect the absorption of light, leading to less accurate readings.
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