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
A WBC count of 2300/mm³ is significantly lower than the normal range (4500-11000/mm³) and indicates leukopenia, which increases the risk of infection. This finding should be reported to the provider.
Choice B rationale
A platelet count of 155,000/mm³ is within the lower end of the normal range (150,000- 450,000/mm³) and does not require immediate reporting.
Choice C rationale
An RBC count of 5 million/mm³ is within the normal range for females (4.2-5.4 million/mm³) and does not require immediate reporting.
Choice D rationale
A hemoglobin level of 12 g/dL is within the normal range for females (12-16 g/dL) and does not require immediate reporting.
Correct Answer is D
Explanation
Choice A rationale
Urinary output is an important postoperative assessment, but it is not the highest priority for a client who has undergone a thoracotomy and lobectomy. Monitoring urinary output helps assess kidney function and fluid balance, but it does not directly address the respiratory status, which is critical in this case. The primary concern after thoracotomy and lobectomy is ensuring adequate oxygenation and ventilation, as the surgery directly impacts the lungs and respiratory function.
Choice B rationale
Pain level is a significant postoperative assessment, as effective pain management is crucial for recovery. However, it is not the highest priority in this scenario. While managing pain is essential to prevent complications such as atelectasis (collapse of part of the lung) due to shallow breathing, the immediate focus should be on assessing and maintaining adequate respiratory function. Pain management can be addressed once the client’s respiratory status is stabilized.
Choice C rationale
Chest tube drainage is a critical postoperative assessment for clients who have undergone thoracotomy and lobectomy. Monitoring chest tube output helps detect complications such as bleeding or pneumothorax (air in the pleural space). However, it is not the highest priority compared to arterial blood gases assessment. While chest tube drainage provides valuable information about the client’s condition, arterial blood gases assessment directly measures the client’s oxygenation and ventilation status, which is paramount in the immediate postoperative period.
Choice D rationale
Arterial blood gases (ABG) assessment is the highest priority for a client who is postoperative following a thoracotomy and lobectomy. ABG analysis provides crucial information about the client’s oxygenation, ventilation, and acid-base balance. This assessment helps detect hypoxemia (low blood oxygen levels), hypercapnia (elevated carbon dioxide levels), and respiratory acidosis, which are critical concerns after lung surgery. Ensuring adequate oxygenation and ventilation is the top priority to prevent respiratory complications and support the client’s recovery.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.