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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Attaching a humidifier bottle to the base of the flow meter is a correct action for the nurse to take for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. A humidifier bottle adds moisture to the oxygen gas, which can prevent dryness and irritation of the nasal passages and the mucous membranes. A humidifier bottle is recommended for oxygen flow rates above 4 L/min.
Choice B reason: Securing the oxygen tubing to the bed sheet near the client’s head is not a correct action for the nurse to take for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Securing the oxygen tubing to the bed sheet can cause the tubing to kink or twist, which can reduce the oxygen flow or delivery. The nurse should secure the oxygen tubing to the client’s clothing or gown, and ensure that there is enough slack to allow the client to move comfortably.
Choice C reason: Applying petroleum jelly to the nares as needed to soothe mucous membranes is not a correct action for the nurse to take for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Petroleum jelly is a flammable substance that can ignite when exposed to oxygen. The nurse should avoid using petroleum jelly or any other oil-based products on the client’s face or nose when using oxygen therapy. The nurse should use water-based products, such as saline gel or nasal spray, to moisturize the nares and mucous membranes.
Choice D reason: Removing the nasal cannula while the client eats is not a correct action for the nurse to take for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Removing the nasal cannula can cause hypoxia, which is a low level of oxygen in the blood. The nurse should keep the nasal cannula in place while the client eats, and monitor the client’s oxygen saturation and respiratory status. The nurse should also assist the client with eating, and encourage small bites and sips to prevent aspiration.
Correct Answer is C
Explanation
Choice A reason: This is incorrect. Right hemiparesis is not a common finding in clients who had a stroke involving the right hemisphere. Hemiparesis is the weakness or partial paralysis of one side of the body. It usually affects the opposite side of the body from the side of the brain that is damaged by the stroke. Therefore, a stroke in the right hemisphere would more likely cause left hemiparesis, not right hemiparesis.
Choice B reason: This is incorrect. Aphasia is not a common finding in clients who had a stroke involving the right hemisphere. Aphasia is the loss or impairment of language functions, such as speaking, understanding, reading, or writing. It usually affects the dominant hemisphere of the brain, which is the left hemisphere for most people. Therefore, a stroke in the right hemisphere would less likely cause aphasia, unless the person is lefthanded or ambidextrous.
Choice C reason: This is correct. Inability to recognize his family members is a common finding in clients who had a stroke involving the right hemisphere. This is a type of agnosia, which is the loss or impairment of the ability to recognize objects, people, sounds, shapes, or smells. The right hemisphere of the brain is responsible for processing visual and spatial information, as well as facial recognition. A stroke in this area can damage the ability to identify familiar faces, even those of close relatives or friends.
Choice D reason: This is incorrect. Difficulty reading is not a common finding in clients who had a stroke involving the right hemisphere. Reading is a language function that involves the recognition and comprehension of written words. It usually depends on the dominant hemisphere of the brain, which is the left hemisphere for most people. Therefore, a stroke in the right hemisphere would less likely cause difficulty reading, unless the person is lefthanded or ambidextrous.
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