When performing postural drainage on a client with chronic obstructive pulmonary disease (COPD), which approach should the nurse use?
Perform the drainage immediately after meals.
Explain that the client may be placed in five positions.
C. Instruct the client to breathe shallow and fast.
The Correct Answer is B
B. Postural drainage involves placing the client in various positions to help drain secretions from different lobes of the lungs. There are typically five standard positions: head-down, head-up, on the side with the affected lung uppermost, on the side with the affected lung lowermost, and lying prone.
A. Performing postural drainage immediately after meals is not recommended because it can increase the risk of vomiting or aspiration, especially in individuals with chronic obstructive pulmonary disease (COPD) who may already have compromised lung function.
C. In postural drainage, the client is typically instructed to breathe deeply and slowly to maximize the effectiveness of the technique.
D. While ABGs may be necessary for monitoring respiratory status in clients with COPD, they are not specifically required prior to performing postural drainage.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Pulse oximetry measures the oxygen saturation of arterial blood, which is a crucial parameter to assess in clients with respiratory distress. Obtaining a pulse oximetry reading will provide information about the client's oxygenation status and help guide further interventions.
B. Huff coughing may be helpful for airway clearance but it may not be the most immediate intervention needed to address the client's respiratory distress.
C. Humidification may be beneficial for airway clearance in the long term but it may not be the most immediate intervention needed to address the client's acute respiratory distress.
D. Nebulizer breathing treatments, such as bronchodilators or corticosteroids, are commonly used to relieve bronchospasm and improve airflow in clients with COPD. However, in this scenario, the client's primary symptoms are dyspnea and tachypnea, indicating acute respiratory distress.
Correct Answer is C
Explanation
C. Type I hypersensitivity reactions, also known as immediate hypersensitivity reactions, involve the production of IgE antibodies in response to an allergen. In this case, the bee sting likely triggered an IgE-mediated immune response, leading to the release of inflammatory mediators such as histamine. The client's symptoms of body rash, shortness of breath, tachycardia, and hypotension are characteristic of anaphylaxis, which is a severe and potentially life-threatening manifestation of Type I hypersensitivity reactions.
A.. Type II hypersensitivity reactions occur when the immune system targets antigens on the body's own cells, leading to cell destruction or dysfunction.
B. Autoimmune responses involve the immune system mistakenly attacking the body's own tissues and organs, leading to inflammation and tissue damage.
D. Cell-mediated hypersensitivity reactions involve the activation of T cells and the release of cytokines, resulting in inflammation and tissue damage. Examples include delayed-type hypersensitivity reactions such as contact dermatitis or tuberculin skin testing reactions.
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