A nurse is caring for a client on a psychiatric unit.

Exhibits

For each potential action, click to specify if the action is indicated or. contraindicated for the client.

The correct answer is Choice C.

Choice A rationale: Eating a meal prior to postural drainage is not recommended.Postural drainage uses gravity to help clear mucus from the lungs, and having a full stomach can cause discomfort and potentially lead to vomiting1.

Choice B rationale: Pancrelipase is a medication that replaces digestive enzymes produced by the pancreas.Most people with cystic fibrosis benefit from taking pancrelipase to aid their digestion2. However, it is not specifically required prior to postural drainage.

Choice C rationale: Using an albuterol inhaler prior to postural drainage is beneficial.Albuterol is a bronchodilator that helps open the airways, making it easier to clear mucus from the lungs34. This is why it’s recommended to use prior to postural drainage.

Choice D rationale: While maintaining good oral hygiene is important for overall health, it is not specifically required prior to postural drainage

Choice A rationale:

Applying a pressure dressing at the IV site might be necessary after removing the catheter, but it does not address the inflammation and discomfort caused by phlebitis. Warm, moist compresses are more appropriate for this situation.

Choice B rationale:

Placing a warm, moist compress on the site is the correct action for phlebitis. Heat helps improve blood circulation, reduce inflammation, and provide relief from pain and discomfort. This choice addresses the client's condition effectively.

Choice C rationale:

Expressing drainage from the IV site and sending it for culture is not necessary in this context. Phlebitis is primarily an inflammatory condition, and drainage culture is not a standard practice for phlebitis.

Choice D rationale:

Inserting a new IV catheter distal to the discontinued IV site is not the immediate action to take for phlebitis. First, the nurse should address the inflammation and pain with warm compresses. If a new IV site is needed, it can be considered after managing the client's symptoms.