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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The right task involves ensuring that the delegated task is appropriate for delegation. In this case, obtaining an oral temperature should have been the correct task; however, the AP
performed the axillary temperature, indicating a deviation from the right task.
B. Right communication involves clear and effective communication between the nurse and the assistive personnel but is not directly related to the task performed.
C. Right person involves ensuring that the task is delegated to a competent and qualified
individual. The issue in this scenario is with the task itself, not the competency of the individual.
D. Right circumstance involves ensuring that the conditions are appropriate for delegation. While the circumstance is important, the primary concern in this case is the mismatch between the task and the method of temperature measurement.
Correct Answer is B
Explanation
A. Palpating the abdomen may exacerbate pain or cause discomfort, and it is not the first action in the assessment of a client with suspected appendicitis. Auscultating bowel sounds is a more appropriate initial step.
B. Auscultating bowel sounds is the priority to assess for signs of bowel obstruction or ileus, which can contribute to the client's symptoms.
C. Offering pain medication can be addressed after the initial assessment and determination of the cause of the symptoms.
D. Administering an antibiotic is premature before a diagnosis is confirmed. The priority is to assess and gather information first.
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