A nurse is caring for a child who has cystic fibrosis and requires postural drainage.
Which of the following actions should the nurse take?
Hold hand flat to perform percussions on the child.
Perform the procedure twice each d
Perform the procedure prior to meals.
Administer a bronchodilator after the procedure
The Correct Answer is C
The correct answer is choice C. Perform the procedure prior to meals.
This is because postural drainage involves positioning the child in different ways to help drain the mucus from the lungs.
If the child has a full stomach, this can cause nausea, vomiting, or aspiration. Therefore, the nurse should perform the procedure before meals or at least 1 hour after meals.
Choice A is wrong because the nurse should not hold the hand flat to perform percussions on the child.
Percussions are rhythmic clapping on the chest wall to loosen the mucus. The nurse should use a cupped hand to create a small air pocket that enhances the vibrations and prevents bruising.
Choice B is wrong because the nurse should not perform the procedure twice a day. The recommended frequency of postural drainage is 3 to 4 times a day, or more if needed, depending on the child’s condition and tolerance.
Choice D is wrong because the nurse should not administer a bronchodilator after the procedure.
A bronchodilator is a medication that relaxes and widens the airways, making it easier to breathe. The nurse should administer a bronchodilator before the procedure to enhance the effectiveness of postural drainage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A option
Fibrinogen level: Fibrinogen is a protein involved in the blood clotting process, but in this case, it is not appropriate because is not the primary laboratory test used to monitor warfarin therapy. Monitoring fibrinogen levels is more relevant in assessing bleeding disorders or certain medical conditions.
Choice B option
PTT (Partial Thromboplastin Time): PTT is another laboratory test used to evaluate blood clotting function, particularly the intrinsic pathway of the clotting cascade. PTT is not routinely used to monitor warfarin therapy; it is more commonly used to monitor other anticoagulant medications like heparin.
Choice C option
The nurse should plan to report the client's INR (International Normalized Ratio) to obtain a prescription for the client's daily warfarin. INR is a critical laboratory test used to monitor the effectiveness and safety of warfarin therapy.
Warfarin is an anticoagulant medication commonly prescribed to prevent and treat blood clots. It works by interfering with the body's ability to use vitamin K to form blood clots. Monitoring the INR is essential because it indicates how long it takes for the blood to clot, and it helps determine if the client's warfarin dosage needs adjustment to achieve the desired level of anticoagulation.
Choice D option
Platelet count: Platelet count is essential to assess the number of platelets in the blood, which are crucial for normal clotting. However, platelet count monitoring is not the primary focus when prescribing warfarin. It is typically used to evaluate thrombocytopenia (low platelet count) or other conditions affecting platelet function.
Correct Answer is A
Explanation
The correct answer is choice A. Limit oral feedings to 30 min in length.
This is because infants with heart failure have difficulty feeding and may become exhausted or dyspneic during prolonged feedings. By limiting the feeding time, the nurse can reduce the energy expenditure and caloric needs of the infant.
Choice B is wrong because weighing the infant every other day is not enough to monitor the fluid status and nutritional intake of the infant. The nurse should weigh the infant daily at the same time using the same scale.
Choice C is wrong because placing the infant in the prone position can compromise the respiratory function and increase the risk of sudden infant death syndrome (SIDS). The nurse should place the infant in a semi-Fowler’s position to facilitate breathing and decrease venous return.
Choice D is wrong because checking the infant’s oxygen saturation every 6 hr is not frequent enough to detect hypoxia or cyanosis. The nurse should monitor the oxygen saturation continuously or at least every 2 hr.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.