A nurse is performing chest percussion on a client who has severe COPD. Which of the following actions should the nurse take?
Place a towel over the area to be percussed.
Ask the client to take shallow, rapid breaths.
Percuss over each area for 10 min.
Maintain client positioning for 45 min.
The Correct Answer is A
A. Place a towel over the area to be percussed: A towel should be placed over the area to be percussed to protect the skin and to reduce discomfort. This is a standard procedure to ensure that the percussion is effective and comfortable for the client.
B. Ask the client to take shallow, rapid breaths: Shallow, rapid breaths should be avoided during chest percussion. The client should take deep, slow breaths to help mobilize secretions and allow for effective lung expansion. Rapid breathing could increase respiratory distress.
C. Percuss over each area for 10 min: Percussion should not be performed for 10 minutes over each area, it is done for 1-2 minutes over each lung field to help loosen mucus and improve drainage. Prolonged percussion could be harmful and unnecessary.
D. Maintain client positioning for 45 min: Typically, positioning is maintained for short periods (usually 10-15 minutes) depending on the area being targeted for percussion. Prolonged positioning may lead to discomfort or other complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Temperature 38.7° C (101.7° F): A temperature of 38.7° C (101.7° F) is elevated and may indicate an infection or inflammation, which is not expected after an EGD. A mild fever could occur briefly, but temperatures above 100.4° F should be monitored closely.
B. Heart rate 110/min: A heart rate of 110/min is elevated and may suggest tachycardia due to pain, anxiety, or potential complications. An elevated heart rate should be assessed further, as it is not typical during the recovery phase of an EGD procedure.
C. Respiratory rate 14/min: A respiratory rate of 14/min is within the normal range for an adult (12-20/min), indicating that the client is breathing comfortably and is recovering well from the procedure. This is an expected finding post-procedure.
D. SpO2 92%: An SpO2 level of 92% is slightly low. The normal range for oxygen saturation is typically 95-100%, and a reading of 92% may indicate mild hypoxemia, which should be further evaluated, especially if the client is recovering from sedation.
Correct Answer is B
Explanation
A. Increased urine output: In disseminated intravascular coagulation (DIC), there is typically decreased urine output due to renal failure or microvascular clotting, not increased output.
B. Petechiae: Petechiae are small red or purple spots on the skin caused by bleeding under the skin. This is a common finding in DIC due to widespread clotting and subsequent bleeding, resulting in tiny hemorrhages.
C. Decreased respirations: Respiratory rate may actually increase in DIC due to hypoxia, sepsis, or pulmonary embolism rather than decrease. Respiratory complications are common in DIC.
D. Bradycardia: Bradycardia (slow heart rate) is not a typical finding in DIC. Instead, tachycardia (increased heart rate) is often observed as a compensatory response to hypovolemia or shock associated with DIC.
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