A nurse is performing postural drainage for a client. Which of the following is an appropriate intervention?

Position the client for secretion drainage by gravity.

Schedule postural drainage following meals.

Give the client a bronchodilator immediately after the procedure.

Instruct the client regarding the importance of fluid restrictions.

Answer and Explanation

The Correct Answer is A

A.   Positioning the client for secretion drainage by gravity is a key component of postural drainage to facilitate the removal of respiratory secretions.
B.   Postural drainage is typically done before meals to avoid potential nausea during the procedure.
C.   Bronchodilators are often administered before postural drainage to open the airways and improve the effectiveness of the procedure.
D.   Encouraging fluid intake is important to help thin respiratory secretions and promote their removal during postural drainage. Fluid restrictions are not typically indicated in this context.

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Correct Answer is C

Explanation

A. 2+ pitting edema is not a contraindication to cold application; in fact, cold application can help reduce edema.
B. A 7.5 cm (3 in) diameter bruise on the ankle is not a contraindication to cold application; cold can help reduce swelling and alleviate pain.
C. Capillary refill of 4 seconds suggests compromised blood flow, and cold application may further impair circulation. It is a contraindication.
D. Warts on the affected ankle are not a contraindication to cold application.

A. Show the client how to use an artificial larynx. B. Arrange a support session for the client. C. Demonstrate the use of esophageal speech. D. Determine the client's reading ability.

Correct Answer is D

Explanation

A. Showing the client how to use an artificial larynx is an important aspect of post-laryngectomy care, but determining the client's reading ability takes precedence as it will significantly impact communication options.
B. Arranging a support session is important for emotional support, but assessing the client's reading ability is more immediate in addressing communication needs.
C. Demonstrating the use of esophageal speech is relevant, but understanding the client's reading ability is a priority before exploring communication alternatives.

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A nurse is performing postural drainage for a client. Which of the following is an appropriate intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A provider prescribes cold application for a client who reports ankle joint stiffness. Which of the following assessment findings should the nurse identify as a contraindication to the application of cold?

Correct Answer is C

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Correct Answer is D

Explanation

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