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?
Instruct to slowly exhale with pursed lips.
Assess pulse and respirations.
Assess characteristics of her sputum.
Auscultate lung fields.
The Correct Answer is D
Choice A rationale
Instructing to slowly exhale with pursed lips is a breathing technique but not the first action to take before the procedure.
Choice B rationale
Assessing pulse and respirations is important but not the first action to take before the procedure.
Choice C rationale
Assessing characteristics of her sputum is important but not the first action to take before the procedure.
Choice D rationale
Auscultating lung fields is the first action to take to assess the client’s current respiratory status and determine the effectiveness of the upcoming procedure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Hypovolemic shock occurs due to a significant decrease in circulating blood volume, leading to inadequate tissue perfusion. Blood loss, such as the 800 mL lost during surgery, is a common cause of hypovolemic shock. The steadily decreasing blood pressure is consistent with this type of shock.
Choice B rationale
Septic shock results from a systemic inflammatory response to infection, leading to vasodilation and maldistribution of blood flow. There is no indication of infection in this scenario.
Choice C rationale
Neurogenic shock results from a loss of sympathetic tone, leading to vasodilation and relative hypovolemia. It is often associated with spinal cord or severe head injury, which is not indicated in this scenario.
Choice D rationale
Obstructive shock occurs when there is an obstruction to blood flow within the cardiovascular system, such as a pulmonary embolism or cardiac tamponade. There is no evidence of such an obstruction in this scenario.
Correct Answer is A
Explanation
Choice A rationale
Disseminated intravascular coagulation (DIC) is caused by abnormal coagulation involving fibrinogen. In DIC, there is widespread activation of the coagulation cascade, leading to the formation of small blood clots throughout the bloodstream. This process consumes clotting factors and platelets, increasing the risk of severe bleeding.
Choice B rationale
DIC is not a genetic disorder involving a vitamin K deficiency. It is typically a secondary condition resulting from other underlying issues such as sepsis, trauma, or malignancy. Vitamin K deficiency can lead to bleeding disorders, but it is not the cause of DIC13.
Choice C rationale
DIC is characterized by a decreased platelet count, not an elevated one. The consumption of platelets and clotting factors in the formation of microthrombi leads to thrombocytopenia and an increased risk of bleeding.
Choice D rationale
DIC is not controllable with lifelong heparin usage. While heparin may be used in certain cases to manage DIC, it is not a lifelong treatment. The management of DIC focuses on treating the underlying cause and supporting the patient through the acute phase of the disorder.
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