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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D"]
Explanation
A. Butter is a dairy product, but it is not typically high in potassium. It is generally safe for clients following a low-potassium diet. Therefore, clients do not need to avoid butter specifically for its potassium content.
B. Yogurt, especially the varieties that are not low-fat or non-fat, can have a significant amount of potassium.
C Pears are generally considered low in potassium and are usually safe to include in a low-potassium diet.
D. Orange juice is a fruit juice and is naturally high in potassium. Clients should avoid or limit orange juice when following a low-potassium diet due to its potassium content.
E. Cabbage is a vegetable that is generally low in potassium. It is safe for clients following a low-potassium diet and does not need to be avoided for its potassium content.
Correct Answer is B
Explanation
A. Performing a blind finger sweep involves inserting a finger into the client's mouth to try and remove an obstruction. This action is not recommended because it can push the obstruction further down the airway, potentially worsening the situation and causing the client to choke.
B. The Heimlich maneuver (abdominal thrusts) is a technique used to clear an obstructed airway in conscious adults. It involves applying sudden upward pressure on the abdomen, between the navel and ribcage, to force air from the lungs to dislodge the obstruction.
C. Turning the client to the side is typically done if the client is unconscious and not breathing normally (recovery position). This position helps maintain a clear airway by allowing any fluids or vomit to drain out of the mouth and prevent obstruction.
D. Tilting the head and lifting the chin is part of the head-tilt, chin-lift maneuver used to open the airway. This maneuver is used when a client is unconscious or unresponsive but breathing. It helps to keep the airway open by lifting the tongue away from the back of the
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