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. Nocturnal enuresis refers to nighttime bedwetting. In clients with paraplegia and neurogenic bladder, nocturnal enuresis can occur due to impaired bladder sensation or control. However, it does not necessarily indicate the immediate need for catheterization unless accompanied by significant bladder distension or discomfort.
B. Suprapubic discomfort or pain suggests bladder distension, which can occur when the bladder fills beyond its capacity. In clients with neurogenic bladder, this discomfort can be an indication that the bladder needs to be emptied to prevent overdistension and potential complications such as urinary retention or bladder rupture. Therefore, suprapubic discomfort may indicate the need for catheterization.
C. Urge incontinence refers to the sudden and uncontrollable urge to urinate, which leads to involuntary leakage of urine. In clients with neurogenic bladder, urge incontinence can occur due to involuntary bladder contractions. While it indicates an inability to control bladder function, it may not always necessitate immediate catheterization unless it persists or is accompanied by other symptoms.
D. Reflex incontinence occurs when the bladder empties without the person's control due to a spinal cord injury or neurological condition. In clients with paraplegia, reflex incontinence is often managed through intermittent catheterization programs. If reflex incontinence episodes are frequent or result in inadequate bladder emptying, it may indicate the need for more frequent catheterization.

A. Protein B. Tea C. Sodium D. Water

Correct Answer is D

Explanation

A. Protein intake, especially animal protein (such as meat and dairy), can increase the excretion of calcium and other minerals into the urine, potentially leading to the formation of certain types of kidney stones (like calcium stones). Therefore, clients with a history of kidney stones are generally advised to moderate their intake of animal protein.
B. Some types of tea, particularly black tea, contain oxalates, which are substances that can contribute to the formation of calcium oxalate kidney stones in susceptible individuals. Therefore, clients with kidney

stones may be advised to limit their intake of tea, especially if they have a history of calcium oxalate stones.
C. High dietary sodium intake can increase calcium excretion in the urine, which may lead to the formation of calcium-containing kidney stones. Therefore, clients with kidney stones are often advised to reduce their sodium intake to help prevent stone formation.
D. Adequate fluid intake, primarily in the form of water, is crucial for preventing kidney stones. Increased water intake helps dilute urine and reduces the concentration of stone-forming substances, making it less likely for crystals to form and grow into stones. The goal is typically to produce at least 2 to 2.5 liters (about 8 to 10 cups) of urine per day.

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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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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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