The nurse is continuing to care for the client.
Vital Signs.
Day 1, 0900:. Temperature (oral) 36.9° C (98.4° F). Heart rate 72/min.
Respiratory rate 16/min.
BP 162/112 mm Hg. Day 1, 0930:. Oxygen saturation 97% on room air.
Temperature (oral) 37.1° C (98.8° F). Heart rate 84/min.
Respiratory rate 18/min.
BP 166/110 mm Hg. Oxygen saturation 99% on room air.
Drag words from the choices below to fill in each blank in the following.
sentence.
The client is at greatest risk for developing Target 1 and Target 2. Conditions.
Placental abruption.
Cervical insufficiency.
Seizures.
Hypoglycemia.
Heart failure.
Correct Answer : C,E
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is: b: Perform the procedure prior to meals.
Choice A rationale: The rationale for Choice A involves understanding the technique of percussion in postural drainage for cystic fibrosis management. Percussion is a component of chest physiotherapy that involves rhythmic clapping or tapping on the chest wall to help loosen and mobilize secretions within the airways. However, holding the hand flat during percussion may not effectively transmit the necessary force to the chest wall for optimal secretion mobilization. Instead, cupping the hands allows for better resonance and transmission of percussion force, enhancing the effectiveness of the procedure.
Choice B rationale: Performing postural drainage prior to meals is the recommended timing for several reasons. Firstly, initiating the procedure before meals allows the child's stomach to be relatively empty, reducing the risk of discomfort, nausea, or vomiting during the procedure. Secondly, performing postural drainage before meals helps prevent aspiration of stomach contents, which can occur if the child vomits during or after the procedure. Aspiration poses significant risks, including lung infection and respiratory distress, particularly in individuals with compromised respiratory function such as those with cystic fibrosis.
Choice C rationale: While bronchodilators may play a role in managing airway obstruction in cystic fibrosis, administering them after postural drainage is not a standard practice. Bronchodilators are typically used to alleviate bronchoconstriction and improve airflow in the lungs. However, their administration after postural drainage may not be directly related to the immediate goals of the procedure, which are to mobilize and clear pulmonary secretions. The timing of bronchodilator administration is often guided by the individual's clinical condition and the presence of symptoms such as wheezing or shortness of breath.
Choice D rationale: Performing postural drainage twice daily may not provide adequate frequency for managing secretions in individuals with cystic fibrosis. The goal of postural drainage is to facilitate the removal of thick, tenacious mucus from the airways to improve respiratory function and reduce the risk of complications such as infections. In cystic fibrosis, mucus clearance is essential for maintaining pulmonary health and preventing exacerbations. Therefore, a more frequent regimen, often including multiple sessions of postural drainage per day, may be necessary to achieve optimal therapeutic outcomes and prevent mucus accumulation and airway obstruction.
Correct Answer is C
Explanation
Choice A rationale:
Allowing the client to have time alone in their room might provide some relief, but it does not address the caregiver's overall stress and the impact on their life. Moreover, constant isolation is not a healthy solution for the client, as social interaction is essential for their well-being.
Choice B rationale:
Discussing methods of communication with the client about resolving problem behaviors is a helpful approach. Effective communication strategies can reduce misunderstandings and challenging behaviors, easing the burden on the caregiver. This choice demonstrates a proactive approach to improving the caregiver's situation.
Choice C rationale:
Assisting the caregiver in arranging for a daycare program for the client is an excellent solution. Adult daycare programs provide a safe and stimulating environment for individuals with Alzheimer's disease, allowing caregivers to have some respite while ensuring the well-being of their loved ones. This choice addresses both the client's needs and the caregiver's stress, making it the most appropriate option.
Choice D rationale:
Suggesting that the caregiver seek a prescription for an antipsychotic medication for the client is not the best course of action without a thorough evaluation by a healthcare provider. Antipsychotic medications have side effects and are typically prescribed based on the client's specific symptoms and needs. Additionally, prescribing medications is beyond the nurse's scope of practice and should be determined by a healthcare provider after a comprehensive assessment.
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