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.

Answer and Explanation

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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Correct Answer is C

Explanation

Correct answer: C

After a cleft‑palate repair, protecting the fresh suture line is paramount. Elbow restraintsare routinely used for the first 7–10 days postoperatively to prevent the toddler from putting fingers or objects into the mouth and disrupting the repair.

A. Keep the infant in a side-lying position. B. Remove elbow restraints while the infant is sleeping C. Administer pain medication around the clock for the first 72 hr. D. Feed the infant half-strength formula for the first 48 hr

Correct Answer is ["C","D"]

Explanation

A. Keep the infant in a side-lying position.

This intervention is not appropriate following cleft palate repair surgery. Placing the infant in a side-lying position may increase the risk of trauma to the surgical site and disrupt the healing process. It's important to follow the surgeon's recommendations regarding positioning, which typically involves keeping the infant in an upright position to minimize strain on the surgical site.

B. Remove elbow restraints while the infant is sleeping.

Elbow restraints are often used postoperatively to prevent the infant from accidentally touching or rubbing the surgical site, which could disrupt wound healing or cause discomfort. Removing the restraints while the infant is sleeping may increase the risk of unintended movement or injury to the surgical site. Therefore, it is not appropriate to remove the restraints while the infant is sleeping.

C. Administer pain medication around the clock for the first 72 hours.

This intervention is appropriate. Pain management is an essential component of postoperative care following cleft palate repair surgery. Administering pain medication around the clock helps to maintain consistent pain relief and prevent spikes in discomfort. Pain management should be tailored to the individual needs of the infant and may include both non-pharmacological measures and analgesic medications.

D. Feed the infant half-strength formula for the first 48 hours.

This intervention is appropriate. Following cleft palate repair surgery, feeding may need to be adjusted to accommodate the infant's comfort and ensure adequate nutrition while minimizing the risk of aspiration. Feeding the infant half-strength formula or other appropriate feeding methods as recommended by the healthcare provider can help prevent stress on the surgical site and reduce the risk of complications such as aspiration pneumonia.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care of a 14-month-old toddler who is 24 h postoperative following a cleft palate repair. Which of the following interventions should the nurse include in the plan?

Correct Answer is C

Explanation

A nurse is contributing to the plan of care for a 2-month-old infant who has just undergone cleft palate repair. The nurse should contribute which of the following interventions to the client's plan of care?

Correct Answer is ["C","D"]

Explanation

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