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 ["15"]

Explanation

750 mg (desired dose) divided by 250 mg (available concentration) equals 3. This result is then multiplied by the volume that contains 250 mg, which is 5 mL. So, 3 times 5 mL equals 15 mL.

Therefore, the nurse should plan to administer 15 mL of the valproate oral solution

A. Allow the client to expel some fluid before continuing. B. Lower the height of the solution container. C. Encourage the client to bear down. D. Stop the enema and document that the client did not tolerate the procedure.

Correct Answer is B

Explanation

A. Expulsion of water does not address the underlying issue.
B. Lowering the height of the solution container can help reduce the force of the fluid entering the colon, which may lessen cramping. This method slows the flow rate of the solution, allowing the client's body to adjust without stopping the procedure entirely.
C. Bearing down (straining) may increase the discomfort and is not recommended during the administration of an enema. It could potentially lead to rectal trauma or increase intrarectal pressure, which is not beneficial during the procedure.

D. While stopping the procedure is an option if the client is unable to tolerate it due to severe discomfort or distress, in this scenario where cramping is the main issue, allowing the client to expel some fluid is more appropriate before deciding to stop the procedure.

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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

Correct Answer is ["15"]

Explanation

A nurse is administering a tap-water enema to a client. The client reports cramping as the nurse instills the irrigating solution. Which of the following actions should the nurse take to relieve the client's discomfort?

Correct Answer is B

Explanation

An assistive personnel (AP) asks a nurse what precautions he should take when measuring the vital signs of a client who has pneumonia. Which of the following responses should the nurse make?

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