When performing postural drainage on a patient with chronic obstructive pulmonary disease (COPD), which approach should the nurse use?
Obtain arterial blood gases (ABGs) prior to procedure.
Explain that the patient may be placed in five positions.
Perform the drainage immediately after meals.
Instruct the patient to breathe shallow and fast.
The Correct Answer is B
Choice A rationale:
While ABGs can provide valuable information about a patient's respiratory status, they are not routinely required prior to postural drainage in patients with COPD.
ABGs might be considered if the patient is experiencing acute respiratory distress or if there are concerns about their oxygenation or ventilation status.
However, in the absence of such concerns, obtaining ABGs would not be necessary and could potentially cause discomfort or anxiety for the patient.
Choice C rationale:
Performing postural drainage immediately after meals is not recommended for patients with COPD.
This is because eating can cause a feeling of fullness in the stomach, which can make it difficult for the patient to breathe deeply and effectively during the procedure.
Additionally, there is a risk of aspiration if the patient were to vomit during or after postural drainage.
It is generally recommended to perform postural drainage at least 1-2 hours after meals to reduce these risks.
Choice D rationale:
Instructing the patient to breathe shallow and fast is not appropriate for postural drainage.
The goal of postural drainage is to help the patient mobilize and expectorate secretions from the lungs.
This is best achieved by encouraging the patient to breathe deeply and slowly, which helps to open up the airways and promote mucus clearance.
Shallow, rapid breathing can actually make it more difficult to clear secretions and can lead to increased shortness of breath.
Choice B rationale:
Explaining that the patient may be placed in five positions is the most appropriate approach for postural drainage in a patient with COPD.
This is because different positions help to drain different areas of the lungs. The five positions typically used for postural drainage are:
Head down position (to drain the lower lobes)
Prone position (to drain the posterior segments of the lungs)
Right lateral position (to drain the right middle lobe and right lower lobe) Left lateral position (to drain the left lower lobe)
Sitting upright position (to drain the upper lobes)
By placing the patient in these different positions, the nurse can help to ensure that all areas of the lungs are drained effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Anorexia is a common symptom of cirrhosis, but it is not the most immediate concern in a client with esophageal varices.
Anorexia can result from various factors, including impaired liver function, hormonal imbalances, early satiety due to ascites,
and nausea.
While it's important to address anorexia to maintain nutritional status, it doesn't directly indicate a life-threatening
complication like bleeding varices.
Choice B rationale:
Brown, foamy urine is a characteristic of kidney problems, specifically proteinuria.
It's not directly associated with esophageal varices or their complications.
While cirrhosis can affect kidney function due to fluid imbalances and impaired filtering, brown, foamy urine wouldn't be the
primary indicator of bleeding varices.
Choice C rationale:
Clay-colored stool is a sign of biliary obstruction, which can occur in cirrhosis due to impaired bile flow.
However, it's not a direct indicator of bleeding varices.
Clay-colored stool results from a lack of bile pigments in the stool, which give it its typical brown color.
Choice D rationale:
Hematemesis, or vomiting of blood, is the most critical symptom to monitor in a client with esophageal varices.
Here's why:
Esophageal varices are enlarged, swollen veins in the esophagus that develop due to increased pressure in the portal venous
system, a common consequence of cirrhosis.
These varices are fragile and prone to rupture, which can lead to massive, life-threatening bleeding.
Hematemesis is a clear sign that variceal bleeding has occurred and requires immediate intervention.
Correct Answer is B
Explanation
The most likely diagnosis for this client isB. Pulmonary embolism and postpartum hemorrhage.
Here’s why:
- Postpartum Hemorrhage:
- The client has a large amount of lochia rubra, indicating significant blood loss.
- Hemoglobin and hematocrit levels are low (7.5 g/dL and 22%, respectively), which is consistent with significant blood loss.
- Symptoms like feeling lightheaded, pale appearance, and cool, clammy skin further support this diagnosis.
- Pulmonary Embolism:
- The client is experiencing shortness of breath, using accessory muscles to breathe, and has an oxygen saturation of 88% on room air.
- Elevated D-dimer levels (1.5 µg/mL) suggest the presence of a clot.
- Arterial Blood Gas (ABG) results show a low PaO2 (60 mmHg) and a slightly acidic pH (7.32), which can be seen in pulmonary embolism.
- The client reports a feeling of tightness in her chest and has a rapid heart rate (120 beats per minute), which are also indicative of a pulmonary embolism.
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