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 ["15"]

Explanation

750 mg (desired dose) divided by 250 mg (available concentration) equals 3. This result is then multiplied by the volume that contains 250 mg, which is 5 mL. So, 3 times 5 mL equals 15 mL.

Therefore, the nurse should plan to administer 15 mL of the valproate oral solution

A. Clamp the chest tubes if it becomes disconnected B. Maintain the drainage container below the level of the client's chest. C. Empty the collection container every shift. D. Add tap water as needed to the suction control chamber.

Correct Answer is B

Explanation

A. Clamping the chest tubes is contraindicated because it can lead to tension pneumothorax, a life- threatening condition where air accumulates in the pleural space under pressure. If the chest tube becomes disconnected, the nurse should immediately place the end of the tube in sterile water to maintain the water seal and prevent air from entering the pleural space.
B. The drainage container must always be kept below the level of the client's chest. This position allows gravity to facilitate drainage from the pleural space into the collection chamber. If the container is positioned above the client's chest, drainage could potentially flow back into the pleural space, leading to complications.
C. It is essential to monitor and record the amount and characteristics of drainage regularly. Emptying the collection container at least once every shift ensures accurate measurement of drainage output and helps in assessing the client's response to treatment.
D. The water-seal chamber of the chest drainage system maintains the desired amount of suction (usually
-20 cm H2O) to facilitate lung re-expansion. This chamber should be filled with sterile water to the recommended level, usually marked on the device. Adding tap water can introduce contaminants and should be avoided.

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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

Correct Answer is ["15"]

Explanation

The nurse is caring for a client who has a pneumothorax and a water-seal chest tube drainage system to suction. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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