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 D
Explanation
The correct answer is Choice D.
Choice A rationale: Acupuncture is typically administered by a trained acupuncturist, not by the nurse. It is not commonly initiated upon arrival at the labor unit.
Choice B rationale: Biofeedback is a technique that usually requires prior training and practice; it is not typically taught for the first time at the beginning of labor.
Choice C rationale: Transcutaneous electrical nerve stimulation (TENS) can help manage back pain during labor but is not specifically used for pelvic pressure.
Choice D rationale: Using an ultrasound picture as a focal point during contractions is a common nonpharmacological pain management technique. Focal points help the client concentrate and manage pain through visualization and distraction.
Correct Answer is B
Explanation
Choice A rationale:
Acetone breath is a symptom of diabetic ketoacidosis (DKA), a complication of diabetes mellitus. It occurs due to the presence of ketones in the breath and is not specific to hypoglycemia. Hypoglycemia is characterized by low blood sugar levels, not elevated ketone levels.
Choice B rationale:
Confusion is a common symptom of hypoglycemia. When blood sugar levels drop significantly, the brain may not receive enough glucose to function properly, leading to confusion, dizziness, and other neurological symptoms.
Choice C rationale:
Polydipsia refers to excessive thirst and is a symptom of hyperglycemia (high blood sugar levels), not hypoglycemia. In hyperglycemic states, the body tries to eliminate excess glucose through urine, leading to increased thirst.
Choice D rationale:
Hot, dry skin is not a typical symptom of hypoglycemia. Hypoglycemia can cause diaphoresis (excessive sweating) and cool, clammy skin due to the body's stress response.
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