A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure, which of the following nursing actions should the nurse complete first?
Instruct to slowly exhale with pursed lips.
Assess pulse and respirations.
Assess characteristics of her sputum.
Auscultate lung fields.
The Correct Answer is D
Choice A rationale
Instructing to slowly exhale with pursed lips is a breathing technique but not the first action to take before the procedure.
Choice B rationale
Assessing pulse and respirations is important but not the first action to take before the procedure.
Choice C rationale
Assessing characteristics of her sputum is important but not the first action to take before the procedure.
Choice D rationale
Auscultating lung fields is the first action to take to assess the client’s current respiratory status and determine the effectiveness of the upcoming procedure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Reviewing laboratory test results for low hemoglobin is important for monitoring anemia, which can be a side effect of radiation therapy. However, it is not the most immediate action to address the specific side effects of radiation therapy to the lung, such as xerostomia (dry mouth) and skin reactions.
Choice B rationale
Assessing the skin for erythema is important as radiation therapy can cause skin reactions, including redness and irritation. However, this action does not directly address the management of xerostomia, which is a common side effect of radiation therapy to the head and neck areas.
Choice C rationale
Monitoring the client for signs of fatigue is essential as fatigue is a common side effect of radiation therapy. However, this action does not specifically address the management of xerostomia, which requires targeted oral care.
Choice D rationale
Providing oral care to manage xerostomia is the correct action. Xerostomia, or dry mouth, is a common side effect of radiation therapy, especially when the head and neck are involved. Oral care helps to alleviate discomfort, prevent infections, and maintain oral health.
Correct Answer is A
Explanation
Choice A rationale
Hypovolemic shock occurs due to a significant decrease in circulating blood volume, leading to inadequate tissue perfusion. Blood loss, such as the 800 mL lost during surgery, is a common cause of hypovolemic shock. The steadily decreasing blood pressure is consistent with this type of shock.
Choice B rationale
Septic shock results from a systemic inflammatory response to infection, leading to vasodilation and maldistribution of blood flow. There is no indication of infection in this scenario.
Choice C rationale
Neurogenic shock results from a loss of sympathetic tone, leading to vasodilation and relative hypovolemia. It is often associated with spinal cord or severe head injury, which is not indicated in this scenario.
Choice D rationale
Obstructive shock occurs when there is an obstruction to blood flow within the cardiovascular system, such as a pulmonary embolism or cardiac tamponade. There is no evidence of such an obstruction in this scenario.
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