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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Dilated appearance of the AV site: A dilated appearance of the AV site is not necessarily a complication. Some dilation may be expected as the graft matures. However, significant or sudden dilation could indicate an issue, such as stenosis or a developing clot, which should be assessed further.

B. Absence of a bruit: The absence of a bruit over an arteriovenous graft is a sign of a potential complication, such as thrombosis or a blockage in the graft. The bruit indicates proper blood flow through the graft. Its absence suggests a lack of blood flow, which requires immediate attention.

C. 2+ left radial pulse: A 2+ pulse is considered normal and indicates adequate peripheral circulation. It does not suggest a complication related to the AV graft.

D. Presence of a palpable thrill: A palpable thrill is typically a normal finding when assessing an AV graft. It is the vibration felt over the graft site due to blood flow and indicates that the graft is functioning properly.

A. Hgb 11.5 g/dL (12 to 16 g/dL) B. Creatinine 3.2 mg/dL (0.5 to 1.1 mg/dL) C. Sodium 146 mEq/L (136 to 145 mEq/L) D. WBC count 12,000/mm3 (5,000 to 10,000/mm3)

Correct Answer is B

Explanation

A. Hgb 11.5 g/dL (12 to 16 g/dL): While this hemoglobin level is slightly below normal, it is not an immediate priority compared to other more concerning values. Anemia could be addressed later with appropriate interventions but is not life-threatening in this case.

B. Creatinine 3.2 mg/dL (0.5 to 1.1 mg/dL): A creatinine level of 3.2 mg/dL is significantly elevated and indicates possible kidney dysfunction or acute kidney injury. Gentamicin is known to be nephrotoxic, and this level requires prompt attention to prevent further renal damage.

C. Sodium 146 mEq/L (136 to 145 mEq/L): Sodium levels are only slightly elevated and do not represent an immediate concern unless the client has symptoms of hypernatremia (e.g., confusion, seizures). While monitoring is required, it is not as urgent as the creatinine.

D. WBC count 12,000/mm3 (5,000 to 10,000/mm3): A WBC count of 12,000/mm3 is mildly elevated, which could suggest an infection or inflammation. However, this is not the priority compared to the kidney function, which could be compromised by gentamicin therapy.

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