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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Ginger is well-known for its ability to promote digestion. It can help alleviate nausea, improve gastric motility, and reduce bloating or discomfort associated with gastrointestinal issues such as a bowel obstruction. Therefore, the client's request for hot ginger tea likely aims to promote digestion, making option A a plausible choice.
B. Ginger is not typically used to regulate blood pressure. Its primary effects are related to digestion, anti- inflammatory properties, and potential immune system support, rather than directly affecting blood pressure regulation.
C. Ginger has anti-inflammatory properties, which can be beneficial in reducing inflammation in the body. However, in the context of the client's request for ginger tea after recovering from a bowel obstruction, the immediate purpose is more likely related to its digestive benefits rather than general anti- inflammatory effects.
D. Ginger has some antioxidant and immune-modulating properties that may contribute to enhancing the immune system. However, its use in Chinese culture, particularly as a tea, is traditionally more associated with digestive health rather than immune enhancement.
Correct Answer is A
Explanation
A. This option is aimed at modifying the consistency of fluids to make them easier to swallow for someone with dysphagia. Thickened liquids are often recommended to prevent aspiration (when food or liquid enters the airway instead of the esophagus) in patients with swallowing difficulties.
B. Placing food on the unaffected side of the mouth, which would be the right side in the case of left-sided weakness, is recommended to aid in easier chewing and swallowing.
C. Temperature can affect how easily food can be swallowed and enjoyed by someone with dysphagia. Extremely hot or cold foods can be more challenging to swallow. However, this dose not address the risk of aspiration.
D. Tipping the head back during swallowing is not recommended because it can increase the risk of choking or aspiration. Instead of tilting the head back, clients with dysphagia should be instructed to maintain an upright position when eating and drinking.
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