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. Change the tubing set every 72 hr:Continuous enteral feeding tubing sets should generally be changed every 24 hours to reduce the risk of bacterial contamination. Changing every 72 hours is too long and increases infection risk.
B. Aspirate residual volume every 4 hr:Aspiration of residual volume every 4 hours is standard practice when providing continuous enteral feedings. This ensures the client is tolerating the feedings and helps prevent aspiration or overfeeding. Large residual volumes may indicate poor gastric emptying.
C. Flush the tubing with 10 mL of water every 2 hr:The tubing should be flushed with 30 mL of water every 4-6 hours (depending on protocol), not just 10 mL, to maintain tube patency and prevent clogging.
D. Heat the formula to 40.5° C (105° F):Formula should not be heated to such a high temperature. It should be administered at room temperature to avoid discomfort and potential damage to the gastrointestinal tract.
Correct Answer is C
Explanation
The nurse should use the abbreviation “BRP” for bathroom privileges.
This is a commonly accepted abbreviation in the medical field and is used to indicate that a client has permission to use the bathroom.
Choice A is not the correct answer because “SC” is not a commonly accepted abbreviation for subcutaneous.
Instead, “SQ” or “SubQ” are more commonly used.
Choice B is not the correct answer because “SS” is not a commonly accepted abbreviation for sliding scale.
Instead, “Sliding Scale” should be written out in full to avoid confusion.
Choice D is not the correct answer because “OJ” is not a commonly accepted medical abbreviation for orange juice.
Instead, “orange juice” should be written out in full to avoid confusion.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.