A nurse is teaching a class at a local senior center regarding safety in the home. A client states, “I am afraid of falling because I live alone and have no one to help me.” Which of the following statements should the nurse make?

Choice A reason: Performing postural drainage immediately after meals risks aspiration and discomfort due to gastric contents shifting during positioning. It should be done 1-2 hours after meals to ensure safety and efficacy in clearing mucus from the lungs, making this timing inappropriate for cystic fibrosis management.
Choice B reason: Performing postural drainage twice daily is recommended for cystic fibrosis to mobilize thick mucus from the lungs, improving airway clearance and reducing infection risk. This frequency balances effectiveness with patient tolerance, aligning with evidence-based guidelines for managing chronic respiratory conditions, making it the correct action.
Choice C reason: Using a percussion vest is an alternative to manual postural drainage but is not specified as the only method. Manual techniques are effective and standard unless a vest is prescribed. This choice assumes equipment availability, which may not apply, making it less universally appropriate than scheduled manual drainage.
Choice D reason: Positioning the child flat during postural drainage is incorrect, as specific angled positions (e.g., head-down) are needed to target lung segments and promote mucus drainage by gravity. Flat positioning reduces effectiveness and may not clear airways adequately, making this an inappropriate technique for cystic fibrosis.

Choice A reason: A heart rate of 60/min is within normal range and does not indicate fluid overload, which may present with tachycardia due to increased cardiac workload. This finding is more consistent with normal physiology or hypovolemia, making it incorrect for identifying fluid overload.
Choice B reason: Skin warm and dry suggests normal hydration or dehydration, not fluid overload, which typically causes edema or moist skin. Dry skin indicates fluid deficit, not excess, making this finding irrelevant and incorrect for assessing fluid overload in this client.
Choice C reason: A respiratory rate of 30/min indicates tachypnea, a sign of fluid overload due to pulmonary edema from excess IV fluids. Fluid in the lungs impairs gas exchange, increasing breathing effort, aligning with clinical manifestations of overload, making this the correct finding.
Choice D reason: Tenting skin turgor indicates dehydration, not fluid overload, as it reflects reduced skin elasticity from fluid loss. Fluid overload causes edema, not tenting, making this finding opposite to the expected presentation and incorrect for this scenario.