A nurse is planning care for a child who has cystic fibrosis and a prescription to receive chest physiotherapy (CPT). Which of the following actions should the nurse plan to take?
Perform CPT immediately after the child eats.
Percuss each lung segment for 15 min.
Administer albuterol prior to CPT.
Perform vibration during the client’s inspirations.
The Correct Answer is C
Choice A reason: Performing CPT immediately after the child eats is not a good action for the nurse to plan to take for a child who has cystic fibrosis and a prescription to receive CPT. CPT involves techniques such as percussion, vibration, and postural drainage that help to loosen and remove mucus from the lungs. Performing CPT right after eating can cause nausea, vomiting, or aspiration, especially if the child has gastroesophageal reflux disease (GERD), which is common in cystic fibrosis. The nurse should plan to perform CPT at least 1 hour before or after meals.
Choice B reason: Percussing each lung segment for 15 min is not a necessary action for the nurse to plan to take for a child who has cystic fibrosis and a prescription to receive CPT. Percussion is a technique that involves clapping the chest with a cupped hand to create vibrations that loosen the mucus in the airways. Percussion can be done manually or with a mechanical device. The duration of percussion depends on the amount and location of the mucus, but it is usually done for 3 to 5 min per lung segment. Percussing for 15 min per segment can be excessive and cause bruising, pain, or fatigue.
Choice C reason: Administering albuterol prior to CPT is a beneficial action for the nurse to plan to take for a child who has cystic fibrosis and a prescription to receive CPT. Albuterol is a bronchodilator that helps to relax the smooth muscles of the airways and improve airflow. Administering albuterol before CPT can enhance the effectiveness of the airway clearance techniques by opening up the airways and making it easier to cough up the mucus.
Choice D reason: Performing vibration during the client’s inspirations is not a correct action for the nurse to plan to take for a child who has cystic fibrosis and a prescription to receive CPT. Vibration is a technique that involves applying pressure and shaking the chest wall during exhalation to help move the mucus out of the lungs. Vibration can be done manually or with a mechanical device. Performing vibration during inspiration can interfere with the inhalation of air and oxygen, and reduce the effectiveness of the technique.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Justice. This answer is incorrect because justice is the ethical principle that ensures fair and equal treatment for all clients, regardless of their personal or social characteristics. Justice does not apply to this situation, as the client is not being discriminated against or denied any resources.
Choice B reason: Veracity. This answer is incorrect because veracity is the ethical principle that requires honesty and truthfulness from the provider and the nurse in providing information and education to the client. Veracity does not apply to this situation, as the client is not being deceived or misled about their condition or treatment options.
Choice C reason: Fidelity. This answer is incorrect because fidelity is the ethical principle that obligates the provider and the nurse to be faithful and loyal to the client and to honor their commitments and promises. Fidelity does not apply to this situation, as the client is not being abandoned or betrayed by the provider or the nurse.
Choice D reason: Autonomy. This answer is correct because autonomy is the ethical principle that respects the client's right to make their own decisions about their health care, even if they are different from the provider's or the nurse's recommendations. Autonomy applies to this situation, as the client is expressing their preference to discontinue the ventilator, which is a life sustaining treatment.
Correct Answer is A
Explanation
Choice A reason: No fluctuations in the water seal chamber. This finding indicates that the lung has expanded and there is no more air leaking from the pleural space. Fluctuations in the water seal chamber are normal when the client breathes, but they should stop when the lung is fully expanded.
Choice B reason: No reports of pleuritic chest pain. This finding does not indicate that the lung has expanded, as pleuritic chest pain can be caused by other factors, such as inflammation or infection of the pleura. Pleuritic chest pain is a sharp pain that worsens with breathing or coughing.
Choice C reason: Occasional bubbling in the water seal chamber. This finding does not indicate that the lung has expanded, as occasional bubbling can be normal or due to a small air leak. Continuous bubbling, however, indicates a large air leak and requires immediate attention.
Choice D reason: Oxygen saturation of 95%. This finding does not indicate that the lung has expanded, as oxygen saturation can be normal or high even with a collapsed lung. Oxygen saturation is the percentage of hemoglobin that is bound to oxygen in the blood.
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