A nurse is planning care for a school-age child who is 4 hr postoperative following appendicitis.

Which of the following actions should the nurse include in the plan of care?

The correct answer is choice C. Perform the procedure prior to meals.

This is because postural drainage involves positioning the child in different ways to help drain the mucus from the lungs.

If the child has a full stomach, this can cause nausea, vomiting, or aspiration. Therefore, the nurse should perform the procedure before meals or at least 1 hour after meals.

Choice A is wrong because the nurse should not hold the hand flat to perform percussions on the child.

Percussions are rhythmic clapping on the chest wall to loosen the mucus. The nurse should use a cupped hand to create a small air pocket that enhances the vibrations and prevents bruising.

Choice B is wrong because the nurse should not perform the procedure twice a day. The recommended frequency of postural drainage is 3 to 4 times a day, or more if needed, depending on the child’s condition and tolerance.

Choice D is wrong because the nurse should not administer a bronchodilator after the procedure.

A bronchodilator is a medication that relaxes and widens the airways, making it easier to breathe. The nurse should administer a bronchodilator before the procedure to enhance the effectiveness of postural drainage.

Tell the client, “You seem to be very upset.”.

This is an example of a therapeutic communication technique that validates the client’s feelings and encourages them to express their emotions verbally rather than physically. It also shows empathy and respect for the client’s perspective.

Choice A is wrong because engaging the panic alarm is not the first action to take when interacting with an agitated client.

The nurse should first try to calm the client down by using verbal and nonverbal communication skills, such as maintaining eye contact, speaking in a calm and clear voice, and avoiding sudden movements or gestures.

Engaging the panic alarm should be done only if the client becomes violent or poses a threat to themselves or others.

Choice B is wrong because using a face shield with a mask when providing care to the client is not relevant to the situation.

This is a personal protective equipment (PPE) that is used to prevent exposure to infectious agents or body fluids, not to manage agitation.

Using a face shield with a mask may also increase the client’s anxiety or paranoia, as they may perceive it as a sign of hostility or fear.

Choice D is wrong because initiating seclusion protocol is not appropriate for a client who is agitated, pacing, and speaking loudly.

Seclusion is a restrictive intervention that involves isolating the client in a locked room to prevent harm to themselves or others.

It should be used only as a last resort when less restrictive measures have failed or are contraindicated, and only with a provider’s order and close monitoring.

Secluding an agitated client may escalate their behavior and violate their rights.

Normal ranges for agitation are not applicable, as agitation is not a quantifiable parameter.

However, some tools that can be used to assess agitation include the Richmond AgitationSedation Scale (RASS), which ranges from -5 (unarousable) to +4 (combative), and the Agitated Behavior Scale (ABS), which ranges from 14 (no agitation) to 56 (severe agitation).