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 ["C"]
Explanation
Leaving the drain until the end of the shift is not appropriate because it could lead to complications such as:
- Hematoma formation:Blood accumulation in the tissues surrounding the drain can put pressure on surrounding structures,potentially impairing blood flow and causing tissue damage.
- Infection:A reservoir containing blood provides a favorable environment for bacterial growth,increasing the risk of infection.
- Drain occlusion:Clotted blood can block the drain,preventing effective drainage and leading to fluid buildup and potential infection.
- Decreased wound healing:Excessive blood loss can delay wound healing by depriving the tissues of necessary oxygen and nutrients.
Removing the drain without the surgeon's order is not appropriate because:
- Premature removal:It could disrupt the healing process and lead to complications such as fluid collection or infection.
- Assessment limitation:Removing the drain would eliminate the ability to monitor ongoing blood loss and could mask potential complications.
A Jackson-Pratt drain works by creating suction when the bulb is squeezed and emptied¹. The bulb should be emptied before it is more than half full to avoid the discomfort of the weight of the drain pulling on the internal tubing and to maintain the suction
Notifying the surgeon about the blood loss is wrong because it is not an urgent situation unless there are signs of excessive bleeding, such as bright red blood, clots, or a sudden increase in the amount of drainage²³. The surgeon should be notified if the drainage is more than 100 ml in 24 hours or if the color changes from serosanguineous (pink) to sanguineous (red)
Correct Answer is B
Explanation
The nurse should respond to the client’s concern by saying “You are worried about having to wear a colostomy bag?” This response acknowledges the client’s concern and allows the client to express their feelings and concerns about the potential colostomy.
Choice A is not an appropriate response because it dismisses the client’s current concern and delays addressing it until after the surgery.
Choice C is not an appropriate response because it does not address the client’s concern about wearing a colostomy bag.
Choice D is not an appropriate response because it shifts the focus away from the client’s concern and onto someone else.
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