A nurse is planning care for a child who has cystic fibrosis and a prescription to receive chest physiotherapy (CPT). Which of the following actions should the nurse plan to take?
Perform CPT immediately after the child eats.
Percuss each lung segment for 15 min.
Administer albuterol prior to CPT.
Perform vibration during the client’s inspirations.
The Correct Answer is C
Choice A reason: Performing CPT immediately after the child eats is not a good action for the nurse to plan to take for a child who has cystic fibrosis and a prescription to receive CPT. CPT involves techniques such as percussion, vibration, and postural drainage that help to loosen and remove mucus from the lungs. Performing CPT right after eating can cause nausea, vomiting, or aspiration, especially if the child has gastroesophageal reflux disease (GERD), which is common in cystic fibrosis. The nurse should plan to perform CPT at least 1 hour before or after meals.
Choice B reason: Percussing each lung segment for 15 min is not a necessary action for the nurse to plan to take for a child who has cystic fibrosis and a prescription to receive CPT. Percussion is a technique that involves clapping the chest with a cupped hand to create vibrations that loosen the mucus in the airways. Percussion can be done manually or with a mechanical device. The duration of percussion depends on the amount and location of the mucus, but it is usually done for 3 to 5 min per lung segment. Percussing for 15 min per segment can be excessive and cause bruising, pain, or fatigue.
Choice C reason: Administering albuterol prior to CPT is a beneficial action for the nurse to plan to take for a child who has cystic fibrosis and a prescription to receive CPT. Albuterol is a bronchodilator that helps to relax the smooth muscles of the airways and improve airflow. Administering albuterol before CPT can enhance the effectiveness of the airway clearance techniques by opening up the airways and making it easier to cough up the mucus.
Choice D reason: Performing vibration during the client’s inspirations is not a correct action for the nurse to plan to take for a child who has cystic fibrosis and a prescription to receive CPT. Vibration is a technique that involves applying pressure and shaking the chest wall during exhalation to help move the mucus out of the lungs. Vibration can be done manually or with a mechanical device. Performing vibration during inspiration can interfere with the inhalation of air and oxygen, and reduce the effectiveness of the technique.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Placing suction equipment at the client’s bedside is a necessary action for the nurse to take for a client who has right sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Acoustic neuroma is a noncancerous tumor that develops on the vestibulocochlear nerve, which is responsible for hearing and balance. It can also affect the adjacent cranial nerves, such as the glossopharyngeal (CN IX) and the vagus (CN X) nerves, which are involved in swallowing and gagging. A client with acoustic neuroma may have difficulty swallowing and clearing secretions, which can increase the risk of aspiration and respiratory infections. The nurse should have suction equipment ready to remove any excess saliva or mucus from the client’s mouth or throat.
Choice B reason: Avoiding the use of warm water to wash the client’s face is not a relevant action for the nurse to take for a client who has right sided acoustic neuroma resulting in impairment of cranial nerves IX and X. The temperature of the water does not affect the function of these nerves or the tumor. The nurse should use gentle and appropriate hygiene measures to clean the client’s face and prevent skin breakdown.
Choice C reason: Providing range of motion exercises to the client’s neck and shoulders is not a priority action for the nurse to take for a client who has right sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Range of motion exercises can help to maintain joint mobility and prevent stiffness, but they are not directly related to the cranial nerve impairment or the tumor. The nurse should consult with a physical therapist to determine the best exercise regimen for the client.
Choice D reason: Applying an eye patch to the client’s right eye is not a helpful action for the nurse to take for a client who has right sided acoustic neuroma resulting in impairment of cranial nerves IX and X. An eye patch is used to protect the eye from injury or infection, or to treat conditions such as strabismus or amblyopia. An eye patch does not affect the function of the cranial nerves IX and X or the tumor. The nurse should monitor the client’s eye movements and vision, as acoustic neuroma can also affect the facial (CN VII) and oculomotor (CN III) nerves, which are involved in blinking and eye movement.
Correct Answer is ["B","C","D"]
Explanation
Choice A reason: This is incorrect. Weight gain is not a manifestation of pulmonary tuberculosis. In fact, weight loss is a common symptom of tuberculosis, as the infection causes the body to use more energy and reduce appetite. Weight loss can also be a result of malnutrition, dehydration, or other complications of tuberculosis.
Choice B reason: This is correct. Night sweats are a manifestation of pulmonary tuberculosis. They occur because the infection causes the body to produce more heat and sweat to fight off the bacteria. Night sweats can also be a sign of fever, which is another symptom of tuberculosis.
Choice C reason: This is correct. Low-grade fever is a manifestation of pulmonary tuberculosis. It occurs because the infection causes the body to raise its temperature to kill the bacteria. Fever can also be accompanied by chills, fatigue, or weakness.
Choice D reason: This is correct. Blood in the sputum is a manifestation of pulmonary tuberculosis. It occurs because the infection causes damage and inflammation to the lungs and the airways, which can bleed and mix with the mucus that is coughed up. Blood in the sputum can also be a sign of a serious complication, such as a ruptured blood vessel or a lung abscess.
Choice E reason: This is incorrect. Flushed cheeks are not a manifestation of pulmonary tuberculosis. They can be caused by various factors, such as embarrassment, exercise, alcohol, or hot weather. Flushed cheeks are not related to the infection or the inflammation of the lungs.
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