Examination, 4th Edition
Chapter 48: Respiratory System
1. A postoperative client with incisional pain complains to the nurse about completing respiratory exercises. The client is willing to do the deep breathing exercises but states that it hurts to cough. The nurse provides gentle encouragement and appropriate pain management to the client, knowing that coughing is needed to:
Expel mucus from the airways.2.Dilate the terminal bronchioles.3.Provide for increased oxygen tension in the alveoli.4.Exercise the muscles of respiration.
Rationale: Coughing is one of the protective reflexes. Its purpose is to move mucus that is in …show more content…
1.“I will use a sterile container from the supply area.”2.“I will send the specimen immediately to the laboratory.”3.“I will ask the client to brush the teeth and rinse the mouth before expectorating.”4.“I will have the client take a shallow breath before coughing.”
Rationale: Because of the nature of the test, the sputum must be collected in a sterile (not a clean) container. The client should brush the teeth and rinse the mouth to decrease the number of contaminating organisms. The client should take a few deep breaths, and then cough forcefully (not spit) into the container. The specimen should be sent directly to the laboratory. It should not be allowed to stand for long periods at room temperature to prevent overgrowth of contaminating organisms.
Test-Taking Strategy: Note the strategic words “incorrect description.” These words indicate a negative event query and ask you to select the incorrect procedure for collecting the sputum sample. Noting the words “shallow breath” in option 4 will direct you to this option. Review the procedure for collecting a sputum sample if you had difficulty with this question.
DIF: Level of Cognitive Ability: Comprehension
REF: Linton, A., & Maebius, N.