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 C
Explanation
The correct answer is choicec. “You will need to wear a mask when outside of your room.”
Choice A rationale:
Visitors wearing protective gowns is important to prevent infection, but it is not the primary teaching point for the patient themselves.
Choice B rationale:
Patients undergoing allogeneic stem cell transplants are typically placed in private rooms to minimize the risk of infection, not semi-private rooms.
Choice C rationale:
Wearing a mask when outside the room is crucial for the patient to protect themselves from infections due to their compromised immune system during the transplant process.
Choice D rationale:
Negative-airflow rooms are used to prevent the spread of airborne infections from the patient to others, not necessarily to keep the air cleaner for the patient.
Correct Answer is D
Explanation
The nurse should place the extremity in a dependent position before inserting an IV catheter.
This helps to dilate the veins and make them more visible and easier to access.
Choice A is wrong because the nurse should choose a site that is distal to the most proximal site on the extremity selected.
This helps to preserve more proximal sites for future use if needed.
Choice B is wrong because applying a cool compress before insertion of an IV catheter can cause vasoconstriction and make it more difficult to access the vein.
Instead, a warm compress can be applied to help dilate the veins.
Choice C is wrong because the tourniquet should be placed above, not below, the proposed insertion site to help dilate the vein and make it easier to access.
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