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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?

A.

Lay down on each side with knees bent and breathe from abdomen.

B.

Increase breathing rate for a full 30 seconds.

C.

Raise hands above the head to expand the diaphragm.

D.

Draw air in through nose and exhale slowly through pursed lips.

Answer and Explanation

The Correct Answer is D

Choice A rationale

 

Laying down on each side with knees bent and breathing from the abdomen is not an effective technique for improving gas exchange in emphysema patients.

 

Choice B rationale

 

Increasing the breathing rate for a full 30 seconds can lead to hyperventilation and is not recommended for improving gas exchange.

 

Choice C rationale

 

Raising hands above the head to expand the diaphragm is not a recognized technique for improving gas exchange in emphysema patients.

 

Choice D rationale

 

Drawing air in through the nose and exhaling slowly through pursed lips is an effective technique for improving gas exchange in emphysema patients. This method helps to keep the airways open longer and improves the removal of trapped air.


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Correct Answer is B

Explanation

Choice A rationale

Autoimmune response is not the correct type of immune reaction for a bee sting. Autoimmune responses involve the body’s immune system attacking its own tissues, which is not the case with bee stings.

Choice B rationale

IgE response hypersensitivity is the correct type of immune reaction for a bee sting. Bee stings can trigger an IgE-mediated hypersensitivity reaction, leading to symptoms such as rash, difficulty breathing, and low blood pressure. This type of reaction is also known as anaphylaxis.

Choice C rationale

Cell-mediated hypersensitivity is not the correct type of immune reaction for a bee sting. Cell-mediated hypersensitivity involves T cells and is typically associated with conditions like contact dermatitis, not bee stings.

Choice D rationale

Type II hypersensitivity is not the correct type of immune reaction for a bee sting. Type II hypersensitivity involves antibody-mediated destruction of cells, which is not the case with bee stings.

Correct Answer is A

Explanation

Choice A rationale

Isolating the client from others is the most important action to prevent the spread of COVID-19. This includes isolating the client from other clients, family, and healthcare workers not wearing proper PPE2.

Choice B rationale

Reporting the COVID-19 result to the local health department is important but not the immediate priority. Isolation takes precedence to prevent transmission.

Choice C rationale

Teaching the client to wear a mask, hand wash, and social distance is essential but secondary to immediate isolation.

Choice D rationale

Counseling family members to monitor for symptoms is important but not the immediate priority. Isolation of the client is the first step.

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