The nurse is caring for a client with emphysema who is mildly dyspneic after ambulation. Which instruction should the nurse provide to the client to improve gas exchange?
Draw air in through the nose and exhale slowly through pursed lips.
Lay down on each side with knees bent and breathe from the abdomen.
Increase breathing rate for a full 30 seconds.
Raise hands above the head to expand the diaphragm.
The Correct Answer is A
Rationale for Choice A:
Pursed-lip breathing:
Creates back pressure in the airways, which helps to keep them open longer during exhalation.
Slows down the breathing rate, allowing for more complete exhalation and better emptying of the lungs. Prevents air trapping, which can worsen shortness of breath.
Promotes relaxation and reduces anxiety, which can also help to improve breathing.
Rationale for Choice B:
Side-lying position with knees bent:
May not be the most effective position for improving gas exchange in a client with emphysema. Could potentially restrict chest expansion and make breathing more difficult.
May not be comfortable for all clients.
Rationale for Choice C:
Increasing breathing rate:
Can lead to hyperventilation, which can worsen shortness of breath and anxiety. Can also cause fatigue and muscle exhaustion.
Rationale for Choice D:
Raising hands above the head:
Does not significantly expand the diaphragm or improve gas exchange. May actually make breathing more difficult for some clients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Chronic pain is a significant concern for this client, but it is not the immediate priority. Pain can be managed with medications and comfort measures, while aspiration can be life-threatening.
Tissue destruction by the tumor is likely contributing to the pain, but addressing the risk of aspiration takes precedence.
Uncontrolled pain can exacerbate anxiety and make it difficult to focus on other interventions, but ensuring airway safety is paramount.
Choice B rationale:
Anxiety and grieving are expected reactions to a diagnosis of esophageal cancer, and they should be addressed as part of the client's care plan. However, they are not the immediate priority in this case.
The progression of the disease is a significant stressor, but attending to the risk of aspiration is essential for the client's safety. Psychological distress can negatively impact coping and quality of life, but addressing physical needs takes precedence.
Choice D rationale:
Imbalanced nutrition is a concern for this client due to dysphagia and anorexia. However, it is not the immediate priority. Nutritional interventions can be implemented once the risk of aspiration is addressed.
Difficulty swallowing can lead to inadequate intake and malnutrition, but ensuring airway safety is the primary concern.
Anorexia can further contribute to nutritional deficits, but preventing aspiration is the most pressing issue.
Choice C is the priority nursing problem because:
The client's dysphagia puts them at immediate risk for aspiration, which can lead to pneumonia, respiratory failure, and even death.
Addressing the risk of aspiration is essential to ensure the client's safety and prevent life-threatening complications. It's crucial to implement interventions to minimize the risk of aspiration, such as:
Elevating the head of the bed during meals and for 30-60 minutes after eating Thickening liquids and pureeing foods
Encouraging small, frequent meals
Monitoring for signs of aspiration, such as coughing, choking, or difficulty breathing
Correct Answer is B
Explanation
Choice A rationale:
Colloidal oatmeal-based lotions can be soothing and moisturizing for dry, itchy skin, but they are not effective in treating the inflammation and scaling associated with psoriasis.
They do not address the underlying hyperproliferation of skin cells that is characteristic of psoriasis.
While they may provide temporary relief of symptoms, they are not a long-term solution for managing the condition.
Choice B rationale:
Topical corticosteroids are the mainstay of treatment for psoriasis.
They work by reducing inflammation, slowing the growth of skin cells, and easing itching and scaling. They come in a variety of strengths and formulations, including creams, ointments, gels, and foams.
The type of corticosteroid and the strength of the medication will depend on the severity of the psoriasis and the location of the lesions.
It's important to follow the healthcare provider's instructions for use carefully, as overuse of topical corticosteroids can lead to side effects such as thinning of the skin and rebound flares.
Choice C rationale:
Topical analgesics, such as lidocaine or benzocaine, can be used to temporarily relieve pain and itching associated with psoriasis.
However, they do not address the underlying inflammation and scaling, and they should not be used as a primary treatment for the condition.
They may be used as adjunctive therapy in conjunction with topical corticosteroids or other psoriasis medications.
Choice D rationale:
Topical antifungal medications are used to treat fungal infections of the skin, such as athlete's foot or ringworm. They are not effective in treating psoriasis, which is an autoimmune condition rather than a fungal infection.
Using a topical antifungal medication for psoriasis could potentially worsen the condition or lead to other skin problems.
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