A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage?
Complete oral hygiene.
Use an ibuterol inhaler.
Take pancrelipase.
Eat a meal.
The Correct Answer is B
The correct answer is B.
Choice A reason: Completing oral hygiene is important for overall health, especially for individuals with cystic fibrosis, as they are at a higher risk for dental problems due to thick mucus that can harbor bacteria. However, oral hygiene does not have a direct impact on the effectiveness of postural drainage. Postural drainage is a technique used to clear mucus from the lungs, and while maintaining oral hygiene is beneficial, it is not a prerequisite for this procedure.
Choice B reason: Using a bronchodilator, such as an ibuterol inhaler, is recommended before postural drainage because it helps to open the airways, making the procedure more effective. Bronchodilators work by relaxing the muscles around the airways, which can become constricted in conditions like cystic fibrosis. This relaxation allows for easier clearance of mucus during postural drainage.
Choice C reason: Pancrelipase is an enzyme supplement used to aid digestion in patients with cystic fibrosis, who often have pancreatic insufficiency. While taking pancrelipase is crucial for nutrient absorption, it is not specifically related to the respiratory treatment of postural drainage. Therefore, it is not necessary to take pancrelipase immediately before this procedure.
Choice D reason: Eating a meal before postural drainage is not recommended. The procedure involves placing the body in positions that facilitate the drainage of mucus from the lungs due to gravity. Having a full stomach can cause discomfort, increase the risk of vomiting, and may hinder the effectiveness of the drainage. It is best to perform postural drainage when the stomach is empty, either before meals or at least 1.5 hours after eating.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Having interdisciplinary team meetings for the client on a regular basis.
This action best promotes communication among staff caring for the client because it allows for consistent and coordinated care planning, information sharing, and goal setting for the client who has expressive aphasia and right hemiparesis following a stroke.
Choice A is wrong because posting swallowing precautions at the head of the client’s bed does not promote communication among staff, but rather informs them of the client’s risk of aspiration due to dysphagia, which is a common complication of stroke.
Choice B is wrong because noting changes in the treatment plan in the client’s medical record is a standard practice that does not necessarily enhance communication among staff, but rather documents the client’s progress and interventions.
Choice D is wrong because recording the client’s progress in the nurses’ notes is also a standard practice that does not necessarily enhance communication among staff but rather provides a summary of the client’s status and care.
Expressive aphasia is an acquired language disorder that affects the ability to produce spoken or written language, while right hemiparesis is a weakness or partial paralysis of the right side of the body.
Both of these conditions are caused by damage to the left hemisphere of the brain, which is responsible for language and motor control of the right side of the body. Stroke and traumatic brain injury are common causes of left hemisphere-damage
Correct Answer is C
Explanation
Choice A reason:
Administer epinephrine subcutaneously. This is not the necessary action to be taken. Epinephrine is used to treat severe allergic reactions (anaphylaxis). However, in this case, the client is experiencing a febrile non-haemolytic transfusion reaction, not an allergic reaction.
Choice B reason:
Place the blood bag in a biohazard bag before discarding. This is not the necessary action to be taken by the nurse. Proper disposal of biohazardous materials is essential, but in this situation, the nurse's priority is to address the client's condition and not the disposal of the blood bag
Choice C reason:
Documentation of the transfusion reaction is crucial for the client's medical history and for future reference. The nurse should record the client's signs and symptoms, the actions taken, and any other relevant information related to the reaction.
Choice D reason
Infuse 500 ml lactated Ringer's IV. This is not necessary action to be taken by the nurse because there is no indication for infusing lactated Ringer's solution in response to the transfusion reaction described. Treatment for febrile non-haemolytic transfusion reactions generally involves stopping the transfusion, administering antipyretics (like acetaminophen) if necessary, and providing supportive care as needed.
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