A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure, which of the following nursing actions should the nurse complete first?

Choice A rationale
While chest pain can occur after pacemaker insertion, it is not the primary concern immediately following the procedure. The nurse should monitor for more critical complications such as arrhythmias, which can indicate pacemaker malfunction or lead displacement.
Choice B rationale
Infection is a potential complication after pacemaker insertion, but it typically develops over a longer period. Immediate monitoring should focus on acute complications such as arrhythmias.
Choice C rationale
Bleeding is a concern after any surgical procedure, including pacemaker insertion. However, the primary immediate concern is monitoring for arrhythmias, which can indicate issues with the pacemaker’s function.
Choice D rationale
Arrhythmias are the primary concern immediately following pacemaker insertion. The nurse should monitor the client for any irregular heart rhythms, which can indicate pacemaker malfunction or lead displacement. Prompt identification and management of arrhythmias are crucial to ensure the pacemaker is functioning correctly.

Choice A rationale
Reviewing laboratory test results for low hemoglobin is important for monitoring anemia, which can be a side effect of radiation therapy. However, it is not the most immediate action to address the specific side effects of radiation therapy to the lung, such as xerostomia (dry mouth) and skin reactions.
Choice B rationale
Assessing the skin for erythema is important as radiation therapy can cause skin reactions, including redness and irritation. However, this action does not directly address the management of xerostomia, which is a common side effect of radiation therapy to the head and neck areas.
Choice C rationale

Monitoring the client for signs of fatigue is essential as fatigue is a common side effect of radiation therapy. However, this action does not specifically address the management of xerostomia, which requires targeted oral care.
Choice D rationale
Providing oral care to manage xerostomia is the correct action. Xerostomia, or dry mouth, is a common side effect of radiation therapy, especially when the head and neck are involved. Oral care helps to alleviate discomfort, prevent infections, and maintain oral health.