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 A
Explanation
The correct answer is choice A. INR.
Warfarin is a vitamin K antagonist that inhibits the synthesis of factors II, VII, IX, and X in the liver.
These factors are part of the extrinsic and common pathways of coagulation, which are measured by the prothrombin time (PT) and the international normalized ratio (INR).
The INR is a standardized way of reporting the PT that accounts for the variability of different reagents and instruments.
The INR is used to monitor the therapeutic effect of warfarin and to adjust the dose accordingly.
The target INR range depends on the indication for warfarin, but it is usually between 2 and 3 for most conditions.
Choice B is wrong because fibrinogen level is not affected by warfarin.
Fibrinogen is a precursor of fibrin, which forms the final step of the coagulation cascade.
Fibrinogen level can be decreased in conditions such as disseminated intravascular coagulation (DIC), liver disease, or severe bleeding. Choice C is wrong because aPTT is not affected by warfarin.
aPTT measures the intrinsic and common pathways of coagulation, which are mainly dependent on factors VIII, IX, XI, and XII.
These factors are not inhibited by warfarin.
aPTT is used to monitor the effect of heparin, a direct antithrombin agent that inhibits thrombin and factor Xa.
Choice D is wrong because platelet count is not affected by warfarin.
Platelets are cell fragments that adhere to damaged blood vessels and form aggregates to initiate hemostasis.
Platelet count can be decreased in conditions such as immune thrombocytopenia (ITP), heparin-induced thrombocytopenia (HIT), or bone marrow suppression.
Normal ranges:
- INR: 0.8-1.2
- Fibrinogen: 200-400 mg/dL
- aPTT: 25-35 seconds
- Platelet count: 150-450 x 10^9/L References:
Correct Answer is C
Explanation
The correct answer is choice C. “Perform chest percussion and postural drainage at least twice daily.” This is because chest percussion and postural drainage are airway clearance techniques that help remove thick mucus from the lungs of children who have cystic fibrosis. This can prevent respiratory infections and improve lung function.
Choice A is wrong because a bronchodilator should be administered before airway clearance therapy, not after. A bronchodilator helps open up the airways and make it easier to cough up mucus.
Choice B is wrong because pancreatic enzymes should be administered with meals and snacks, not on an empty stomach.
Pancreatic enzymes help digest fats, proteins, and carbohydrates in children who have cystic fibrosis. This can prevent malnutrition and growth failure.
Choice D is wrong because there is no need to restrict gluten intake for children who have cystic fibrosis, unless they also have celiac disease.
Gluten is a protein found in wheat, barley, and rye that can cause intestinal damage in people who have celiac disease. Cystic fibrosis does not affect the ability to tolerate gluten.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today