A nurse is assisting with the plan of care for a client who has pneumonia and requires chest percussion, vibration, and postural drainage. Which of the following actions should the nurse plan to complete first?

Provide mouth care.

Auscultate lung fields.

Position the client so that the lung area to be drained is above the client's trachea.

Cup hands and tap on the client's chest repeatedly.

Answer and Explanation

The Correct Answer is B

A.   Mouth care is an important aspect of overall care, but it is not directly related to chest percussion, vibration, and postural drainage. It can be done before or after these procedures as needed for client comfort and oral hygiene.
B.   Auscultating the lung fields is a crucial step before initiating chest percussion, vibration, and postural drainage. It helps the nurse assess the current status of lung sounds, identify areas of congestion or consolidation, and determine the appropriate areas for percussion and drainage.
C.   Positioning the client correctly is essential to facilitate effective drainage. By positioning the lung area to be drained above the trachea, gravity assists in moving secretions towards the larger airways for removal.
D.   Chest percussion involves rhythmically tapping the chest wall with cupped hands to loosen and mobilize secretions in the lungs. This action helps to facilitate drainage during postural drainage.

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Correct Answer is B

Explanation

A. Urinary frequency refers to the need to urinate more often than usual. It does not typically cause changes in the color, clarity, or odor of urine. It may be associated with conditions like urinary tract infections (UTIs) or other urinary issues but does not directly cause dark amber, cloudy, or foul-smelling urine.
B. A UTI is a common cause of changes in urine characteristics. Dark amber color can indicate concentrated urine due to dehydration or the presence of blood. Cloudiness suggests the presence of pus or bacteria, while an unpleasant odor can be due to bacterial growth. UTIs often cause these symptoms due to inflammation and infection of the urinary tract.
C. Urinary incontinence refers to involuntary loss of urine. It does not typically cause changes in the appearance or odor of urine unless it leads to urine pooling and subsequent bacterial growth, which could potentially cause odor. However, incontinence itself is not a direct cause of dark amber, cloudy urine with an unpleasant odor.
D. Urinary retention occurs when the bladder does not empty completely or at all. It can lead to concentrated urine (dark amber color) due to prolonged storage in the bladder. Cloudiness and an unpleasant odor can occur if there is bacterial growth in stagnant urine. Therefore, urinary retention can contribute to the observed urine characteristics.

A. Perform a blind finger sweep. B. Begin the Heimlich maneuver. C. Turn the client to the side. D. Tilt the head and lift the chin.

Correct Answer is B

Explanation

A. Performing a blind finger sweep involves inserting a finger into the client's mouth to try and remove an obstruction. This action is not recommended because it can push the obstruction further down the airway, potentially worsening the situation and causing the client to choke.
B. The Heimlich maneuver (abdominal thrusts) is a technique used to clear an obstructed airway in conscious adults. It involves applying sudden upward pressure on the abdomen, between the navel and ribcage, to force air from the lungs to dislodge the obstruction.
C. Turning the client to the side is typically done if the client is unconscious and not breathing normally (recovery position). This position helps maintain a clear airway by allowing any fluids or vomit to drain out of the mouth and prevent obstruction.
D. Tilting the head and lifting the chin is part of the head-tilt, chin-lift maneuver used to open the airway. This maneuver is used when a client is unconscious or unresponsive but breathing. It helps to keep the airway open by lifting the tongue away from the back of the

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A nurse is assisting with the plan of care for a client who has pneumonia and requires chest percussion, vibration, and postural drainage. Which of the following actions should the nurse plan to complete first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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