Postural drainage with percussion and vibration is ordered twice daily for a patient with chronic obstructive pulmonary disease (COPD). Which intervention should the nurse include in the plan of care?

Administer bronchodilator medication before the procedure

Restrict fluid intake before the procedure

Perform deep breathing exercises after the procedure

Place the patient in a supine position during the procedure

Answer and Explanation

The Correct Answer is A

A. Administering a bronchodilator before postural drainage helps open the airways, making it easier to mobilize and clear secretions during the procedure. This improves the effectiveness of the therapy.

B. Restricting fluid intake before the procedure is not appropriate. Adequate hydration is essential to thin secretions, making them easier to clear during postural drainage.

C. While deep breathing exercises are beneficial for lung expansion and oxygenation, they are not specifically required immediately after postural drainage. The focus is on clearing secretions during the procedure.

D. The supine position is not ideal for postural drainage. The client should be placed in specific positions depending on the lung segment being targeted, such as Trendelenburg or lateral decubitus positions, to facilitate drainage by gravity.

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Correct Answer is A

Explanation

A. Flail chest occurs when multiple ribs are fractured in more than one location, creating a free-floating segment of the chest wall. This segment moves paradoxically during respiration, meaning it moves inward during inspiration and outward during expiration, which impairs effective breathing and oxygenation.

B. Paralysis of the chest wall may occur in conditions like spinal cord injuries but is not the defining characteristic of flail chest.

C. While decreased oxygenation can occur with flail chest due to impaired ventilation, the defining feature is the paradoxical movement of the fractured rib segment.

D. Weakness of the diaphragm can impair lung expansion, but this is characteristic of conditions like diaphragmatic paralysis, not flail chest.

A. Check the client’s PTT level immediately B. Explain this is a result of the medication C. Notify the healthcare provider immediately D. Assess the client’s blood pressure and heart rate

Correct Answer is B

Explanation

A. Checking the client’s PTT level is unnecessary in this situation because low molecular weight heparin (e.g., enoxaparin) does not typically require PTT monitoring. This test is more relevant for clients receiving unfractionated heparin.

B. Small purple hemorrhagic areas (ecchymosis) at the injection sites are a common and expected side effect of low molecular weight heparin. The nurse should explain to the client that this is a normal reaction to the medication and does not indicate a serious issue.

C. Notifying the healthcare provider immediately is not warranted unless the client shows signs of excessive bleeding, such as hematomas, significant bruising, or a drop in blood pressure. The described ecchymosis is a minor and expected side effect.

D. Assessing the client’s blood pressure and heart rate is a reasonable step if there are concerns about significant bleeding or hemodynamic instability. However, in this case, the described symptoms are localized and do not suggest systemic bleeding.

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Postural drainage with percussion and vibration is ordered twice daily for a patient with chronic obstructive pulmonary disease (COPD). Which intervention should the nurse include in the plan of care?

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