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 A
Explanation
Choice A rationale:
Maintains airway patency: Leaving the old ties in place until the new ones are secure ensures that the tracheostomy tube remains in the correct position and prevents accidental decannulation, which could obstruct the airway and lead to respiratory distress or arrest. This is the most important priority in tracheostomy care.
Prevents tube displacement: Accidental decannulation can occur during tie changes, especially in patients with copious secretions or who are restless or agitated. Keeping the old ties in place acts as a safety measure to keep the tube in position even if the new ties are not immediately secured.
Allows for adjustments: If the new ties are not tied correctly or are too tight, the old ties can be loosened or removed to make adjustments without compromising the airway.
Minimizes anxiety: Leaving the old ties in place can help to reduce anxiety in patients who are apprehensive about the tie- changing process, as it provides a sense of security and ensures that the tube will not be dislodged.
Choice B rationale:
Increases risk of skin irritation: Knots tied close to the tube can rub against the skin, causing irritation, discomfort, and potential skin breakdown, especially in patients with sensitive skin or who have copious secretions.
Impinges on blood flow: Tight knots can also constrict blood vessels, potentially impairing circulation to the skin around the tracheostomy site.
Difficult to remove in emergencies: Knots tied too close to the tube can be challenging to untie quickly in case of an emergency, such as accidental decannulation or the need to suction secretions.
Choice C rationale:
Not appropriate for all patients: Disposable, soft foam collars with self-adhesive fastening may not be suitable for patients with copious secretions, as the adhesive may not adhere well to moist skin.
May not provide adequate support: These collars may not provide the same level of support as traditional tracheostomy ties, especially in patients with active neck movement or who are at risk of accidental decannulation.
Potential for skin irritation: The adhesive on the collar can also irritate the skin around the tracheostomy site in some patients.
Choice D rationale:
May not prevent irritation: Placing knots laterally may not completely eliminate the risk of skin irritation, as the ties can still rub against the skin with neck movement or when the patient is lying down.
Could lead to accidental loosening: Knots tied laterally may be more prone to accidental loosening, especially if the patient is restless or agitated.
Correct Answer is B
Explanation
Choice A rationale:
Hypothermia is a condition in which the body's core temperature falls below 95°F (35°C). It is not directly indicated by the client's vital signs as presented in the question.
Other factors that would more strongly suggest hypothermia include exposure to cold environments, immersion in cold water, or impaired thermoregulation due to conditions like hypothyroidism or alcohol intoxication.
Choice C rationale:
Hypotension is a condition in which blood pressure is abnormally low. It is also not directly indicated by the client's vital signs as presented in the question.
Hypertension, on the other hand, is a condition in which blood pressure is abnormally high.
The client's history of hypertension, and the fact that he takes enalapril (an antihypertensive medication), suggests that he may be more likely to experience hypertension than hypotension.
Choice D rationale:
Hypertension, as mentioned above, is a condition in which blood pressure is abnormally high.
While it's possible that the client is experiencing hypertension, the question specifically asks about the condition indicated by the client's vital signs.
Tachypnea, or rapid breathing, is a more direct indication of the client's respiratory distress, which is a common symptom of pneumonia.
Choice B rationale:
Tachypnea is the most likely condition indicated by the client's vital signs.
Tachypnea is often a sign of respiratory distress, which can be caused by a variety of conditions, including pneumonia. When a person has pneumonia, their lungs become inflamed and filled with fluid, making it difficult to breathe.
This can lead to rapid, shallow breathing, which is called tachypnea.
Other signs of respiratory distress that may be present in a client with pneumonia include: Coughing
Wheezing Chest pain
Feeling short of breath
Use of accessory muscles to breathe (e.g., muscles in the neck and chest) Nasal flaring
Cyanosis (a bluish tint to the skin)
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