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?
Complete oral hygiene.
Use an ibuterol inhaler.
Take pancrelipase.
Eat a meal.
The Correct Answer is B
The correct answer is B.
Choice A reason: Completing oral hygiene is important for overall health, especially for individuals with cystic fibrosis, as they are at a higher risk for dental problems due to thick mucus that can harbor bacteria. However, oral hygiene does not have a direct impact on the effectiveness of postural drainage. Postural drainage is a technique used to clear mucus from the lungs, and while maintaining oral hygiene is beneficial, it is not a prerequisite for this procedure.
Choice B reason: Using a bronchodilator, such as an ibuterol inhaler, is recommended before postural drainage because it helps to open the airways, making the procedure more effective. Bronchodilators work by relaxing the muscles around the airways, which can become constricted in conditions like cystic fibrosis. This relaxation allows for easier clearance of mucus during postural drainage.
Choice C reason: Pancrelipase is an enzyme supplement used to aid digestion in patients with cystic fibrosis, who often have pancreatic insufficiency. While taking pancrelipase is crucial for nutrient absorption, it is not specifically related to the respiratory treatment of postural drainage. Therefore, it is not necessary to take pancrelipase immediately before this procedure.
Choice D reason: Eating a meal before postural drainage is not recommended. The procedure involves placing the body in positions that facilitate the drainage of mucus from the lungs due to gravity. Having a full stomach can cause discomfort, increase the risk of vomiting, and may hinder the effectiveness of the drainage. It is best to perform postural drainage when the stomach is empty, either before meals or at least 1.5 hours after eating.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E","F"]
Explanation
Answer is B, C, D, E, F. These are the findings that suggest possible elder abuse or neglect.
- B: Client’s report of lack of food in home. This may indicate neglect by the adult child who is supposed to provide adequate nutrition for the client.
- C: Client’s report of lack of access to bank accounts. This may indicate financial abuse by the adult child who is controlling the client’s money without his permission.
- D: Client’s avoidance of eye contact. This may indicate emotional abuse by the adult child who is intimidating or threatening the client.
- E: Client’s report of weight loss. This may indicate neglect by the adult child who is not meeting the client’s basic needs or physical abuse by the adult child who is causing bodily harm to the client.
- F: Numerous bruises in various stages of healing. This may indicate physical abuse by the adult child who is hitting or injuring the client.
A: ECG results. This is not a finding that suggests elder abuse or neglect. It is a diagnostic test that measures the electrical activity of the heart and can help detect cardiac problems. It does not provide information about the client’s social or emotional well-being.
Normal ranges for vital signs:.
- Temperature: 36.1°C to 37.2°C (97°F to 99°F).
- Heart rate: 60 to 100 beats per minute.
- Blood pressure: less than 120/80 mm Hg.
- Respiratory rate: 12 to 20 breaths per minute.
- SpO2: 95% to 100% on room air. Table for BMI categories:
|
BMI |
Weight Status |
|
Below 18.5 |
Underweight |
|
18.5 to 24.9 |
Normal |
|
25.0 to 29.9 |
Overweight |
|
30.0 and above |
Obese |
The client’s BMI is 18.3, which indicates he is underweight and may be malnourished or have a medical condition that causes weight loss.
Correct Answer is B
Explanation
The correct answer is choice B. Increase exercise.
Exercise can help stimulate bowel movements and prevent constipation, which is a common side effect of opioid medications.
Exercise can also improve blood circulation, reduce stress, and enhance mood, which can benefit clients who have chronic pain.
Choice A is wrong because decreasing insoluble fiber intake can worsen constipation.
Insoluble fiber adds bulk to the stool and helps it pass more easily through the colon.
Clients who take opioid medications should increase their intake of insoluble fiber from sources such as whole grains, fruits, vegetables, nuts, and seeds.
Choice C is wrong because drinking less water can lead to dehydration and hardening of the stool, which can make it more difficult to pass.
Clients who take opioid medications should drink plenty of water to keep the stool soft and moist.
Choice D is wrong because taking a laxative every day can cause dependence, tolerance, and electrolyte imbalance.
Laxatives should be used only as a last resort and under the guidance of a health care provider.
Clients who take opioid medications should try other methods of preventing constipation first, such as increasing exercise, fiber, and water intake.
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