A nurse is performing postural drainage with percussion and vibration for a client who has cystic fibrosis.
Which of the following actions should the nurse take?
Cover the area of percussion with a towel.
Schedule postural drainage after meals.
Instruct the client to exhale quickly during vibration.
Perform percussion over the lower back.
The Correct Answer is A
This is because chest percussion uses clapping of the chest using a cupped hand to vibrate the airways of the lungs and move and break apart the mucus inside the lungs.
Covering the area of percussion with a towel can help to reduce discomfort during the procedure.
Choice B is wrong because postural drainage should not be scheduled after meals.
It is best to schedule postural drainage before meals or at least 1-2 hours after meals to prevent discomfort or vomiting.
Choice C is wrong because, during vibration, the client should inhale deeply and exhale slowly.
Choice D is wrong because percussion should not be performed over the lower back.
It should be performed over the chest and back, avoiding areas such as the spine and breastbone.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The first two actions the nurse should take are to obtain a sputum culture and a chest X-ray.
These tests can help diagnose the cause of the client’s symptoms and guide treatment.
Choice A is wrong because administering antibiotics and bronchodilators should only be done after a diagnosis has been made.
Choice B is wrong because airborne precautions and isolation may not be necessary depending on the cause of the client’s symptoms.
Choice C is wrong because cough suppressants and antihistamines may not be appropriate treatments depending on the cause of the client’s symptoms.
Correct Answer is A
Explanation
According to self-efficacy theory, learning develops from multiple sources, including perceptions of one’s past performance, vicarious experiences, performance feedback, affective/physiological states, and social influences.
Choice B is wrong because simply explaining the need for education to the client may not necessarily increase their motivation to learn.
Choice C is wrong because seeking family approval by agreeing to a teaching plan may not necessarily increase the client’s motivation to learn.
Choice D is wrong because the nurse’s empathy about the client having to self-inject may not necessarily increase their motivation to learn.
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