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 A
Explanation
Choice A reason:
"You might experience altered taste sensations" is the correct statement. When providing teaching to a client about to undergo external radiation therapy for cancer, the nurse should include information about potential side effects and what to expect during the treatment. One common side effect of radiation therapy, especially when the treatment is focused on or near the head and neck region, is altered taste sensations. Radiation can affect the taste buds and lead to changes in how foods taste.
Choice B reason:
"Use rubbing alcohol to remove the ink markings. “The statement is incorrect. The ink markings made on the client's skin are used as reference points for the radiation therapy treatment. It is essential not to remove these markings, as they are crucial for accurate positioning during each treatment session. The nurse should instruct the client not to tamper with the markings, and the radiation therapy team will remove them when they are no longer needed.
Choice C reason:
"Wear a binder over the radiation site." The statement is incorrect. Wearing a binder over the radiation site is not a standard practice during external radiation therapy. The client should be instructed to follow the specific guidelines provided by the radiation therapy team regarding clothing and positioning during treatments. The use of binders or other tight clothing over the treatment area may not be recommended, as it can cause discomfort or interfere with the delivery of radiation.
Choice D reason
"Wash your skin thoroughly with a washcloth after each treatment." Is incorrect statement. During radiation therapy, the skin in the treatment area can become sensitive. It is essential for the client to follow the specific instructions provided by the radiation therapy team regarding skin care. Generally, the client should avoid using harsh soaps or scrubbing the skin vigorously. Instead, they should gently cleanse the area with a mild soap or as directed by their healthcare providers.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Explanation
safety followed by the client’s pain.
The nurse should first address the client’s safety because it is the most basic and essential need according to Maslow’s hierarchy of needs. The client may be at risk of abuse or neglect from his adult child, as evidenced by the bruises, body odor, unclean clothes, low BMI, and submissive behavior. The nurse should assess the client for signs of physical or emotional abuse and report any suspicions to the appropriate authorities. The nurse should also provide a safe and supportive environment for the client and encourage him to express his feelings and concerns.
The nurse should then address the client’s pain because it is a physiological need that affects the client’s comfort and well-being. The client rates his pain as 8 on a 0 to 10 scale and is not moving his right arm. The nurse should assess the client’s arm for signs of injury, such as swelling, deformity, or bleeding. The nurse should also administer analgesics as prescribed and monitor the client’s response to pain relief. The nurse should also provide non-pharmacological interventions, such as ice packs, elevation, or distraction.
The other choices are less urgent than safety and pain. The client’s abrasions are superficial and do not pose a significant risk of infection or bleeding. The client’s hygiene is important but not a priority at this time. The client’s BMI indicates that he is underweight, but this is a chronic condition that requires long-term nutritional intervention. The client’s heart rate is slightly elevated but not alarming, and may be due to pain, anxiety, or dehydration.
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