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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
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.
Correct Answer is A
Explanation
A) "My child has some swelling around her eyelids and mouth."
In this scenario, the parent reporting swelling around the toddler's eyelids and mouth after receiving immunizations is the nurse's priority concern. Swelling around the eyes and mouth can be indicative of a possible allergic reaction, such as angioedema or anaphylaxis, which can be a serious and life-threatening condition. Immediate assessment and intervention are needed to address this potential allergic reaction.
The other findings, while important, are not as immediately concerning:
B) A temperature of 100.7 degrees Fahrenheit is a mild fever, which can be expected as a side effect of some vaccines. It may not be the nurse's immediate priority, but it should still be monitored.
C) A toddler's decreased feeding of 2 ounces during her last feeding may be related to her discomfort or fever after immunizations. It's essential to monitor this but not an immediate priority.
D) Crying when touched at the injection site is a common response to immunizations and, while uncomfortable for the child, is not typically a cause for immediate concern. However, it should still be addressed with comfort measures.
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