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 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Placing the client's hands in warm water is a method to stimulate urination and is appropriate for clients experiencing difficulty voiding.
Choice B rationale:
Performing a fundal massage is incorrect choice in this scenario.
Choice C rationale:
Administering a benzodiazepine is not appropriate for this situation. Benzodiazepines are a class of medications primarily used for anxiety, insomnia, and seizures. There is no indication for the use of benzodiazepines in this case, as the client's inability to urinate is likely related to a physiological issue postpartum, not anxiety or seizures.
Choice D rationale:
Placing an ice pack on the client's perineum is not the correct intervention for this situation. Ice packs on the perineum are typically used to reduce swelling and relieve pain after childbirth. However, the client's inability to urinate suggests a potential issue within the urinary system, and a fundal massage to promote uterine contractions would be more appropriate.
Correct Answer is C
Explanation
Changing a central venous catheter dressing for a client who is receiving IV therapy. Sterile gloves are required for any invasive procedure and when contact with any sterile site, tissue, or body cavity is expected. A central venous catheter is inserted into a large vein near the heart and can be a source of infection if not handled properly. Changing the dressing requires sterile gloves to prevent contamination of the catheter site and the bloodstream.
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