A nurse is performing postural drainage for a client. Which of the following is an appropriate intervention?
Position the client for secretion drainage by gravity.
Schedule postural drainage following meals.
Give the client a bronchodilator immediately after the procedure.
Instruct the client regarding the importance of fluid restrictions.
The Correct Answer is A
A. Positioning the client for secretion drainage by gravity is a key component of postural drainage to facilitate the removal of respiratory secretions.
B. Postural drainage is typically done before meals to avoid potential nausea during the procedure.
C. Bronchodilators are often administered before postural drainage to open the airways and improve the effectiveness of the procedure.
D. Encouraging fluid intake is important to help thin respiratory secretions and promote their removal during postural drainage. Fluid restrictions are not typically indicated in this context.
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Related Questions
Correct Answer is A
Explanation
A. Obtaining apical and radial rates simultaneously allows the nurse to assess for a pulse deficit by comparing the two rates. A pulse deficit is present when the apical rate (heard with a
stethoscope) is greater than the radial rate (palpated at the wrist).
B. Palpating pulses in the lower extremities is not specific for assessing a pulse deficit and may not accurately reflect the cardiac output.
C. Checking blood pressure in left and right arms assesses for blood pressure differences but does not specifically address a pulse deficit.
D. Comparing the pulse strength in the upper extremities does not directly assess for a pulse deficit; simultaneous assessment of apical and radial rates is more appropriate.
Correct Answer is B
Explanation
A. Ciprofloxacin 200 mg IV q12h x 7 days is a clear and acceptable prescription.
B. "Dx" is an unaccepted abbreviation; it is not appropriate for documentation and may lead to confusion.
C. "Hourly 180" is unclear and may need clarification; it could refer to an hourly measurement or a specific order, but it lacks clarity.
D. Acetaminophen 1000 mg PO QD is a clear and acceptable prescription.
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