A nurse is performing chest percussion on a client who has severe COPD. Which of the following actions should the nurse take?
Ask the client to take shallow, rapid breaths.
Place a towel over the area to be percussed.
Percuss over each area for 10 min.
Maintain client positioning for 45 min.
The Correct Answer is B
A. Instructing the client to take shallow, rapid breaths is incorrect; deep breathing is encouraged to promote effective airway clearance.
B. Placing a towel or thin cloth over the area to be percussed is appropriate to protect the skin and enhance client comfort during chest percussion.
C. Percussing over each area for 10 minutes is excessive and could cause discomfort or injury; typically, 1 to 2 minutes per area is sufficient.
D. Maintaining positioning for 45 minutes is unnecessary and could lead to discomfort or skin breakdown; position changes should occur more frequently.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The ST segment represents the time between ventricular depolarization and the beginning of repolarization. It does not measure conduction through the atria or AV node.
B. The PP interval measures the distance between atrial depolarizations (P waves) and is used to assess atrial rhythm, not conduction time.
C. The PR interval measures the time from the beginning of atrial depolarization (P wave) to the beginning of ventricular depolarization (QRS complex). It reflects impulse conduction from the sinus node through the atria, AV node, and His-Purkinje system, making it the correct answer.
D. The QRS complex represents ventricular depolarization, not the conduction time through the atria or AV node.
Correct Answer is A
Explanation
A. Drinking 4 to 6 ounces of juice (such as orange juice) is a fast-acting carbohydrate source recommended to quickly raise blood glucose levels during a hypoglycemic episode. This is part of the standard 15/15 rule: give 15 grams of fast-acting carbohydrate, then recheck blood glucose in 15 minutes.
B. 1 teaspoon of glucose gel is typically insufficient; usually, 1 tablespoon or more is required to deliver 15 grams of carbohydrate.
C. Two glucose tablets may be too little, depending on the brand; most tablets contain only 4 grams each, and 15 grams is typically required. Also, waiting 1 hour to recheck blood glucose is too long—blood glucose should be checked after 15 minutes.
D. Peanut butter with crackers is a slower-acting carbohydrate and fat combination, better for preventing future episodes after blood sugar is stabilized—not for initial treatment of acute hypoglycemia.
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