A primary health care provider orders chest physiotherapy with percussion and vibration for a client. After the health care provider leaves, the client says, “I still don’t understand the purpose of this therapy.” Which statement should be included in the nurse’s response?

Promotes the flow of secretions to the base of the lungs.

Eliminates the need to cough.

Helps clear the airways of excessive secretions.

Limits the production of bronchial mucus.

Answer and Explanation

The Correct Answer is C

Choice A reason: While chest physiotherapy can help mobilize secretions, it does not specifically promote the flow of secretions to the base of the lungs. The primary goal is to loosen and mobilize secretions so they can be coughed up and cleared from the airways. This helps improve overall lung function and oxygenation.

Choice B reason: Chest physiotherapy does not eliminate the need to cough. In fact, coughing is an essential part of the process as it helps expel the loosened secretions from the airways. The therapy aims to make coughing more effective by loosening the mucus.

Choice C reason: The primary purpose of chest physiotherapy with percussion and vibration is to help clear the airways of excessive secretions. This is particularly important for patients with conditions like chronic obstructive pulmonary disease (COPD), cystic fibrosis, or pneumonia, where mucus buildup can obstruct the airways and impair breathing. By loosening and mobilizing the secretions, the therapy facilitates their removal through coughing.

Choice D reason: Chest physiotherapy does not limit the production of bronchial mucus. It focuses on clearing existing mucus from the airways rather than reducing its production. The production of mucus is influenced by underlying conditions and may require other treatments to manage.

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Correct Answer is A

Explanation

Effective hand hygiene is crucial in preventing the spread of infections in healthcare settings. The Centers for Disease Control and Prevention (CDC) and other health organizations provide guidelines on proper hand hygiene techniques to ensure maximum effectiveness.

Choice A Reason:

“Rub soap on hands for 20 seconds.”

This is the correct action for effective hand hygiene. According to the CDC, scrubbing your hands for at least 20 seconds is essential to remove germs effectively. This duration ensures that all surfaces of the hands, including the backs, between the fingers, and under the nails, are thoroughly cleaned. The CDC recommends singing the “Happy Birthday” song twice as a timer to ensure you scrub for the full 20 seconds.

Choice B Reason:

“Allow hands and arms to dry.”

While drying hands is an important step in hand hygiene, it is not the primary action that makes hand hygiene effective. The focus should be on the thorough scrubbing and cleaning of the hands. After washing, hands should be dried using a clean towel or air dryer to prevent the transfer of germs from wet hands.

Choice C Reason:

“Hold the hands higher than the elbows.”

This technique is often used in surgical hand antisepsis to prevent water from running from the hands down to the elbows, potentially contaminating the hands again. However, for routine hand hygiene, this is not necessary. The primary focus should be on the thorough washing and scrubbing of the hands.

Choice D Reason:

“Adjust the water temperature to feel hot.”

The temperature of the water is less important than the act of scrubbing itself. The CDC states that hands can be washed with either warm or cold water. The key is to use soap and scrub all surfaces of the hands for at least 20 seconds. Hot water can actually be harsh on the skin and is not required for effective hand hygiene.

A. Sleep deprivation B. Normal signs of aging C. Dementia D. Delirium

Correct Answer is D

Explanation

Choice A Reason:

Sleep deprivation is incorrect. While sleep deprivation can cause confusion and disorientation, it is less likely to cause abrupt onset of altered mental status and hallucinations. Sleep deprivation typically results in gradual cognitive decline and fatigue rather than sudden changes.

Choice B Reason:

Normal signs of aging is incorrect. Normal aging can involve some cognitive decline, but it does not typically cause sudden and severe symptoms like hallucinations and significant disorientation. These symptoms are more indicative of an acute condition.

Choice C Reason:

Dementia is incorrect. Dementia involves a gradual decline in cognitive function over time and does not typically present with sudden onset of symptoms. While dementia can include hallucinations and disorientation, these symptoms usually develop progressively.

Choice D Reason:

Delirium is correct. Delirium is characterized by a sudden onset of confusion, disorientation, and changes in mental status. It is often triggered by acute medical conditions such as infections, including UTIs. Elderly patients are particularly susceptible to delirium, which can include symptoms like hallucinations and severe confusion.

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A primary health care provider orders chest physiotherapy with percussion and vibration for a client. After the health care provider leaves, the client says, “I still don’t understand the purpose of this therapy.” Which statement should be included in the nurse’s response?

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to perform hand hygiene. Which action should the nurse take for hand hygiene to be effective?

Correct Answer is A

Explanation

A nurse is caring for an elderly client diagnosed with a urinary tract infection (UTI). The family reports an abrupt onset of altered mental status, disorientation, and intermittent hallucinations. The nurse would identify these signs to be consistent with which sensory alteration?

Correct Answer is D

Explanation

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