A nurse is performing postural drainage with percussion and vibration for a client who has cystic fibrosis.
Which of the following actions should the nurse take?
Cover the area of percussion with a towel.
Schedule postural drainage after meals.
Instruct the client to exhale quickly during vibration.
Perform percussion over the lower back.
The Correct Answer is A
This is because chest percussion uses clapping of the chest using a cupped hand to vibrate the airways of the lungs and move and break apart the mucus inside the lungs.
Covering the area of percussion with a towel can help to reduce discomfort during the procedure.
Choice B is wrong because postural drainage should not be scheduled after meals.
It is best to schedule postural drainage before meals or at least 1-2 hours after meals to prevent discomfort or vomiting.
Choice C is wrong because, during vibration, the client should inhale deeply and exhale slowly.
Choice D is wrong because percussion should not be performed over the lower back.
It should be performed over the chest and back, avoiding areas such as the spine and breastbone.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A nurse can delegate the task of performing a simple dressing change to an assistive personnel.
Delegation is an essential nursing skill that allows a qualified healthcare worker, like an RN, to transfer routine and low-risk duties to nursing assistive personnel.
This frees up the RN’s time to address more pressing matters, including critical patients and tasks.
Choice A is wrong because changing IV tubing is not a task that can be delegated to assistive personnel.
Choice C is wrong because inserting an NG tube is not a task that can be delegated to assistive personnel.
Choice D is wrong because evaluating the healing of an incision is not a task that can be delegated to assistive personnel.
These tasks require the expertise and training of a licensed nurse.
Correct Answer is C
Explanation
“This test will provide information about the function of your liver.” An alanine aminotransferase (ALT) test measures the level of ALT in the blood, which is an enzyme found primarily in the liver.
Elevated levels of ALT can indicate liver damage or disease.
Choice A, “This test will indicate if you are at risk for developing blood clots,” is not correct as an ALT test does not provide information about blood clot risk.
Choice B, “This test will determine if your heart is performing properly,” is not correct as an ALT test does not provide information about heart function.
Choice D, “This test is used to check how your kidneys are working,” is not correct as an ALT test does not provide information about kidney function.
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