A nurse is caring for a child who is to receive percussion, vibration, and postural drainage. Which of the following actions should the nurse take first?
Instruct the client to cough
Perform vibration while the client exhales slowly through the nose.
Percuss the upper posterior chest.
Administer albuterol by nebulizer.
The Correct Answer is D
A. Instruct the client to cough. Coughing is generally encouraged after chest physiotherapy to help expel loosened secretions, but it is not the first action. The bronchodilator should be administered first to maximize the effectiveness of the chest physiotherapy.
B. Perform vibration while the client exhales slowly through the nose. Vibration is a component of chest physiotherapy used to help loosen secretions during exhalation, but it is performed after the bronchodilator is administered and once the client is positioned properly.
C. Percuss the upper posterior chest. Percussion helps to mobilize secretions but is typically done after the bronchodilator has been administered to allow for more effective airway clearance.
D. Administer albuterol by nebulizer. Administering albuterol first dilates the airways, making it easier to mobilize and clear secretions during percussion, vibration, and postural drainage.
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Related Questions
Correct Answer is B
Explanation
Infusion rate (mL/hour) = Total volume (mL) / Total time (hours)
Given:
Child's weight: 10 kg
Ordered volume: 40 mL/kg
Total time: 4 hours
First, calculate the total volume of Lactated Ringer's solution needed:
Total volume = 40 mL/kg × 10 kg = 400 mL
Then, divide the total volume by the total time to find the infusion rate:
Infusion rate = 400 mL / 4 hours = 100 mL/hour
Correct Answer is D
Explanation
A. Allow the child to see and touch IV tubing and supplies.
Allowing the child to see and touch the IV tubing and supplies can help familiarize them with the equipment and reduce anxiety. However, there may be a more appropriate action to take first.
B. Explain to the child's parents what role they will have during the procedure.
While it's important to involve the child's parents and inform them of their role during the procedure, the priority should be to prepare the child for the insertion itself.
C. Describe the procedure using visual aids.
Using visual aids can be helpful in explaining the procedure to the child and providing a clear understanding of what will happen. However, there may be a more appropriate action to take first.
D. Ask the child what he knows about the procedure.
This is the correct answer. Asking the child what they already know about the procedure allows the nurse to assess their understanding and address any misconceptions or concerns they may have. It also helps the nurse tailor their explanation to the child's level of understanding and provide information that is relevant and meaningful to them.
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