A nurse is assisting with the plan of care for a client who has pneumonia and requires chest percussion, vibration, and postural drainage. Which of the following actions should the nurse plan to complete first?

Provide mouth care.

Auscultate lung fields.

Position the client so that the lung area to be drained is above the client's trachea.

Cup hands and tap on the client's chest repeatedly.

Answer and Explanation

The Correct Answer is B

A.   Mouth care is an important aspect of overall care, but it is not directly related to chest percussion, vibration, and postural drainage. It can be done before or after these procedures as needed for client comfort and oral hygiene.
B.   Auscultating the lung fields is a crucial step before initiating chest percussion, vibration, and postural drainage. It helps the nurse assess the current status of lung sounds, identify areas of congestion or consolidation, and determine the appropriate areas for percussion and drainage.
C.   Positioning the client correctly is essential to facilitate effective drainage. By positioning the lung area to be drained above the trachea, gravity assists in moving secretions towards the larger airways for removal.
D.   Chest percussion involves rhythmically tapping the chest wall with cupped hands to loosen and mobilize secretions in the lungs. This action helps to facilitate drainage during postural drainage.

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Correct Answer is C

Explanation

A. Malnutrition itself is not a direct cause of healthcare-associated infections (HAIs).
B. While having multiple caregivers can potentially increase the risk of transmission of infections if proper hand hygiene and infection control practices are not followed, it is not a direct cause of HAIs. Proper adherence to infection control protocols mitigates this risk.
C. Urinary catheterization is a common cause of healthcare-associated infections, particularly urinary tract infections (UTIs). Catheters provide a pathway for bacteria to enter the urinary tract, leading to infection if not managed properly or if left in place longer than necessary.
D. Chlorhexidine washes are actually used as an infection prevention measure rather than a cause of HAIs. Chlorhexidine is an antiseptic agent that is effective against a wide range of microorganisms and is used for preoperative skin cleansing, central line care, and other procedures to reduce the risk of infections.

A. Gelatin B. Shellfish C. Yeast D. Eggs

Correct Answer is B

Explanation

A. Gelatin is derived from collagen obtained from various animal body parts. It is commonly used in medications, including some capsules and intravenous (IV) preparations. It has no association with cardiac catheterization procedure.
B. This is because the contrast dye used during the procedure typically contains iodine, which can cause an allergic reaction in susceptible individuals.
C. Yeast allergies are reactions to proteins found in yeast, commonly used in baking and brewing and sometimes present in vaccines and medications. However, it has no association with cardiac catheterization procedure.
D. Egg allergies involve reactions to proteins found in eggs and can be present in vaccines, some medications, and some foods. However, it has no association with cardiac catheterization procedure.

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A nurse is assisting with the plan of care for a client who has pneumonia and requires chest percussion, vibration, and postural drainage. Which of the following actions should the nurse plan to complete first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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