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 C

Explanation

A. Malnutrition itself is not a direct cause of healthcare-associated infections (HAIs).
B. While having multiple caregivers can potentially increase the risk of transmission of infections if proper hand hygiene and infection control practices are not followed, it is not a direct cause of HAIs. Proper adherence to infection control protocols mitigates this risk.
C. Urinary catheterization is a common cause of healthcare-associated infections, particularly urinary tract infections (UTIs). Catheters provide a pathway for bacteria to enter the urinary tract, leading to infection if not managed properly or if left in place longer than necessary.
D. Chlorhexidine washes are actually used as an infection prevention measure rather than a cause of HAIs. Chlorhexidine is an antiseptic agent that is effective against a wide range of microorganisms and is used for preoperative skin cleansing, central line care, and other procedures to reduce the risk of infections.

A. At the end of the collection time, urinate and save the urine in a separate container. B. At the beginning of the collection time, urinate and then discard the urine. C. Save each urine collection in a separate container. D. Keep the collection container at room temperature.

Correct Answer is B

Explanation

A. This instruction is incorrect for a 24-hour urine collection. During a 24-hour urine collection, the client should urinate into a designated collection container at the start of the collection period and continue to collect all urine voided over the next 24 hours. The nurse should instruct the client to empty their bladder completely at the end of the 24-hour period into the same container used throughout the collection period. This ensures that all urine produced over the 24 hours is included in the specimen.
B. Discarding the first urine voided at the beginning of the collection period is a common instruction for some types of urine tests, such as for urinary catecholamines or specific timed collections. However, for a 24-hour urine collection, the client should start collecting urine from the very first void and include all subsequent urine produced over the next 24 hours.
C. This instruction is incorrect for a 24-hour urine collection. All urine produced during the 24-hour period should be saved in a single designated collection container. Using separate containers for each void would make it difficult to accurately measure the total volume of urine collected over the specified time frame.

D. Storing the urine collection container at room temperature is generally appropriate for a 24-hour urine collection. This helps maintain the stability of the urine sample and ensures accurate test results. Refrigeration may be required if specified by the healthcare provider for specific tests, but this should be clearly communicated to the client if necessary.

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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

A nurse is preparing an in-service presentation about preventing health care-associated infections (HAIs). The nurse should include which of the following as a common cause of these infections?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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