A nurse is caring for an adolescent client who has cystic fibrosis.
Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage?

Eat a meal.

Take pancrelipase.

Use an albuterol inhaler.

Complete oral hygiene.

Answer and Explanation

The Correct Answer is C

The correct answer is c. Use an albuterol inhaler.

Choice A reason: Eating a meal before postural drainage is not recommended because it can cause discomfort, nausea, or vomiting due to the positions required for the procedure.

Choice B reason: Taking pancrelipase is important for aiding digestion in cystic fibrosis patients, but it is not specifically related to the preparation for postural drainage.

Choice C reason: Bronchodilators like albuterol are used before airway clearance techniques to open the airways, making it easier to clear mucus during postural drainage.

Choice D reason: While maintaining oral hygiene is important for overall health, it is not a preparation step for postural drainage.

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Correct Answer is B

Explanation

The correct answer is choice B: Dyspnea.

Choice B rationale: Dyspnea, or difficulty breathing, is a potential indication of a recurrent pulmonary embolism and should be reported immediately. Early detection and intervention are crucial to prevent life-threatening complications.

Choice A rationale: Hypotension may be a concerning finding in postoperative clients, but it is not the priority for a client with a history of pulmonary embolism. Hypotension could be related to various factors like bleeding or anesthesia effects.

Choice C rationale: Dry cough may occur as a result of irritation or inflammation in the airway due to the surgical procedure or anesthesia. Although it should be monitored, it is not the highest priority in this situation.

Choice D rationale: Tachycardia can be a common postoperative finding due to pain, anxiety, or other factors. Although it should be monitored and addressed, it is not the most critical concern in this case. Dyspnea is more closely related to a possible pulmonary embolism and should be reported promptly.

A. "Since I retired, I have entered many gardening competitions." B. "I'm so glad I've retired because the work was making me sick and depressed." C. "I had to retire because my boss didn't like me." D. "There were lay-offs at my company, so I journaled about what I accomplished during my career." .

Correct Answer is A

Explanation

Choice A rationale:

"Since I retired, I have entered many gardening competitions." This statement indicates compensation as a defense mechanism. Compensation involves emphasizing personal strengths in one area to shift focus from failure or weakness in another. In this case, the client is finding fulfillment and recognition in gardening competitions after retiring, compensating for the loss of work-related identity.

Choice B rationale:

Expressing relief about retirement due to negative work experiences doesn’t necessarily indicate compensation. It could be a coping mechanism, but it doesn't align with the compensation defense mechanism, which involves overachieving in one area to compensate for deficiencies in another.

Choice C rationale:

Choice D rationale:

Journaling about career accomplishments after layoffs indicates sublimation, not compensation. Sublimation is a defense mechanism where unacceptable impulses or behaviors are transformed into socially acceptable actions or pursuits, like channeling frustration or disappointment into creative or productive activities such as journaling.

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A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is postoperative and has a history of pulmonary embolism. Which of the following findings is the priority for the nurse to report to the provider?

Correct Answer is B

Explanation

A nurse is assessing the coping strategies of a client who has recently retired.Which of the following statements by the client indicates that the client is using compensation as a defense mechanism?

Correct Answer is A

Explanation

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A nurse is caring for an adolescent client who has cystic fibrosis.
Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage?