A nurse is developing a care plan for a patient with pneumonia who requires chest percussion, vibration, and postural drainage.
What should the nurse plan to do first?
Cup hands and tap on the patient’s chest repeatedly.
Position the patient so that the lung area to be drained is above the trachea.
Provide mouth care.
Auscultate lung fields.
The Correct Answer is D
The correct answer is choice d. Auscultate lung fields.
Choice A rationale:
Cupping hands and tapping on the patient’s chest is part of the chest percussion technique, which helps to loosen mucus. However, it is not the first step. Before performing any physical intervention, the nurse must assess the patient’s current respiratory status.
Choice B rationale:
Positioning the patient so that the lung area to be drained is above the trachea is part of postural drainage. This step is crucial but should be done after assessing the patient’s lung fields to determine the areas that need drainage.
Choice C rationale:
Providing mouth care is important for overall hygiene and to prevent infection, especially in patients with respiratory conditions. However, it is not directly related to the immediate assessment and intervention for chest physiotherapy.
Choice D rationale:
Auscultating lung fields is the first step because it allows the nurse to assess the patient’s respiratory status and identify areas with abnormal breath sounds, which will guide the subsequent interventions like chest percussion, vibration, and postural drainage. This assessment ensures that the interventions are targeted and effective.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
A colostomy is a surgical opening in the abdomen that allows stool to pass through the colon and out of the body. While a colostomy may increase the risk of certain complications, such as dehydration and skin irritation, it does not directly increase the risk of aspiration. This is because the colostomy bypasses the upper digestive tract, where aspiration typically occurs.
Choice B rationale:
An ileostomy is a similar surgical opening in the abdomen, but it diverts the small intestine rather than the colon. Like a colostomy, an ileostomy does not directly increase the risk of aspiration. However, it may lead to dehydration and electrolyte imbalances, which could indirectly contribute to aspiration risk.
Choice C rationale:
Enteral feedings through an NG tube are a common way to provide nutrition to patients who cannot eat by mouth. However, these feedings can also increase the risk of aspiration. This is because the NG tube bypasses the normal swallowing mechanisms, which help to protect the airway. If the feeding tube is not properly positioned or if the patient has impaired gastric motility, formula could enter the lungs and cause aspiration pneumonia.
Choice D rationale:
A chest tube is a drainage tube that is inserted into the chest cavity to remove air or fluid. While a chest tube may cause some discomfort and respiratory issues, it does not directly increase the risk of aspiration.
Correct Answer is B
Explanation
Choice A rationale:
Incorrect. Patients have a legal right to access their medical records under the Health Information Portability and Accountability Act (HIPAA). Denying access is a violation of patient rights and could lead to legal consequences.
Undermines patient autonomy and trust. Patients have a right to know what information is in their medical records and to participate in their own healthcare decisions. Denying access can erode trust in the healthcare system.
Potential for errors and misunderstandings. If patients cannot review their records, they may not be able to identify errors or misunderstandings that could impact their care.
Choice B rationale:
Correct. This response upholds patient rights while ensuring that the request for access is documented and handled appropriately.
Protects patient privacy and confidentiality. The written request process helps to ensure that only the patient or their authorized representative has access to the records.
Provides a mechanism for tracking and auditing access requests. This can help to prevent unauthorized access and ensure compliance with HIPAA regulations.
Choice C rationale:
Incorrect. Patients have a right to access their records at any time, not just when they are being discharged.
Delays access to information. Patients may need to review their records to make informed decisions about their care, even if they are not being discharged.
Potential for records to be lost or misplaced. There is a risk that records could be lost or misplaced if they are not provided to the patient until discharge.
Choice D rationale:
Incorrect. Patients do not need to provide a reason for wanting to access their medical records.
Intrusive and unnecessary. Patients may feel uncomfortable or embarrassed about having to explain their reasons for wanting to access their records.
Potential for discrimination. Patients may be less likely to request access to their records if they feel that they will be judged or questioned about their reasons for doing so.
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