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?
Eat a meal.
Take pancrelipase.
Use an albuterol inhaler.
Complete oral hygiene.
The Correct Answer is C
The correct answer is Choice C.
Choice A rationale: Eating a meal prior to postural drainage is not recommended. Postural drainage uses gravity to help clear mucus from the lungs, and having a full stomach can cause discomfort and potentially lead to vomiting1.
Choice B rationale: Pancrelipase is a medication that replaces digestive enzymes produced by the pancreas. Most people with cystic fibrosis benefit from taking pancrelipase to aid their digestion2. However, it is not specifically required prior to postural drainage.
Choice C rationale: Using an albuterol inhaler prior to postural drainage is beneficial. Albuterol is a bronchodilator that helps open the airways, making it easier to clear mucus from the lungs34. This is why it’s recommended to use prior to postural drainage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
The client with epidural analgesia and weakness in the lower extremities might be experiencing complications related to the epidural, such as epidural hematoma or nerve damage. However, the immediate concern is the client with a hip fracture and new onset of tachypnea. Tachypnea can indicate a pulmonary embolism or worsening respiratory status due to the fracture, both of which require urgent assessment and intervention.
Choice B rationale:
The client with diabetes mellitus and an HbA1c of 6.89% has a well-controlled blood glucose level. This condition does not require immediate attention compared to the client with a hip fracture and tachypnea, who might be experiencing a life-threatening complication.
Choice C rationale:
The client with a hip fracture and new onset of tachypnea is the priority for assessment. Tachypnea can be a sign of respiratory distress, which could indicate a pulmonary embolism or worsening lung function due to the fracture. Timely intervention is crucial to prevent further complications.
Choice D rationale:
The client with sinus arrhythmia and cardiac monitoring is stable and does not require immediate attention compared to the client with a hip fracture and tachypnea.
Correct Answer is D
Explanation
The correct answer is choice d.
Choice A rationale:
Washing the penis from scrotum to tip using a spiral motion can trap bacteria under the foreskin and increase risk of infection.
Choice B rationale:
Soap helps remove dirt and bacteria, reducing infection risk. Soapy water is preferred over plain water for perineal care.
Choice C rationale:
While hand hygiene is crucial, sterile gloves are not typically required for routine perineal care in an SCI patient unless there's a break in the skin or a high risk of infection.
Choice D rationale:
Discarding the washcloth after cleansing the urethral meatus is essential to prevent transferring bacteria to other areas.
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