When performing postural drainage on a patient with chronic obstructive pulmonary disease (COPD), which approach should the nurse use?

Obtain arterial blood gases (ABGs) prior to procedure.

Explain that the patient may be placed in five positions.

Perform the drainage immediately after meals.

Instruct the patient to breathe shallow and fast.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

While ABGs can provide valuable information about a patient's respiratory status, they are not routinely required prior to postural drainage in patients with COPD.

ABGs might be considered if the patient is experiencing acute respiratory distress or if there are concerns about their oxygenation or ventilation status.

However, in the absence of such concerns, obtaining ABGs would not be necessary and could potentially cause discomfort or anxiety for the patient.

Choice C rationale:

Performing postural drainage immediately after meals is not recommended for patients with COPD.

This is because eating can cause a feeling of fullness in the stomach, which can make it difficult for the patient to breathe deeply and effectively during the procedure.

Additionally, there is a risk of aspiration if the patient were to vomit during or after postural drainage.

It is generally recommended to perform postural drainage at least 1-2 hours after meals to reduce these risks.

Choice D rationale:

Instructing the patient to breathe shallow and fast is not appropriate for postural drainage.

The goal of postural drainage is to help the patient mobilize and expectorate secretions from the lungs.

This is best achieved by encouraging the patient to breathe deeply and slowly, which helps to open up the airways and promote mucus clearance.

Shallow, rapid breathing can actually make it more difficult to clear secretions and can lead to increased shortness of breath.

Choice B rationale:

Explaining that the patient may be placed in five positions is the most appropriate approach for postural drainage in a patient with COPD.

This is because different positions help to drain different areas of the lungs. The five positions typically used for postural drainage are:

Head down position (to drain the lower lobes)

Prone position (to drain the posterior segments of the lungs)

Right lateral position (to drain the right middle lobe and right lower lobe) Left lateral position (to drain the left lower lobe)

Sitting upright position (to drain the upper lobes)

By placing the patient in these different positions, the nurse can help to ensure that all areas of the lungs are drained effectively.

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Correct Answer is D

Explanation

Measuring oxygen saturation is not directly relevant to the administration of vancomycin or the monitoring of its potential side effects. While oxygen saturation is important to assess in patients with respiratory concerns, it does not provide information about kidney function, which is essential for safe vancomycin use.

Choice B rationale:

Auscultating bowel sounds, while a part of general abdominal assessment, is not the most crucial action before administering vancomycin. Vancomycin is not known to have significant effects on bowel motility, and its primary concern is nephrotoxicity.

Choice C rationale:

Assessing body temperature can be helpful in evaluating for infection, but it is not the most specific or sensitive indicator of vancomycin-related adverse effects. Fever can be a sign of various conditions, and it does not directly assess kidney function.

Choice D rationale:

Checking serum creatinine is the most essential action before administering vancomycin because it allows for assessment of kidney function. Vancomycin is primarily excreted by the kidneys, and impaired renal function can lead to elevated drug levels and increased risk of nephrotoxicity. By checking serum creatinine, the nurse can ensure that the patient's kidney function is adequate to safely excrete vancomycin and can adjust the dosage or frequency of administration if necessary.

A. Place client on oxygen 2 to 4 liters and maintain oxygen saturation at or above 95%. B. Stat ventilation/perfusion (V/Q) of chest. C. Stat 2 views chest x-ray. D. Stat Complete blood count (CBC), basic metabolic panel (BMP), and blood cultures. E. Send sputum for culture & sensitivity.

Correct Answer is ["A","C","D"]

Explanation

The correct answer is choice A, C, and D.

Choice A rationale:

The patient’s oxygen saturation is at 94%, which is just below the normal range of 95-100% for healthy adults breathing room air. Administering oxygen 2 to 4 liters to maintain oxygen saturation at or above 95% is a standard intervention to ensure adequate oxygenation.

Choice B rationale:

A stat ventilation/perfusion (V/Q) scan is typically ordered for suspected pulmonary embolism, which is not indicated by the patient’s current data. The patient’s symptoms do not specifically suggest a V/Q mismatch that would necessitate this diagnostic test.

Choice C rationale:

A chest x-ray is a common diagnostic tool for evaluating the lungs and heart, especially when a patient presents with symptoms that may indicate respiratory or cardiac issues. Given the patient’s temperature and heart rate, which are slightly elevated, a chest x-ray can help identify any potential underlying conditions.

Choice D rationale:

Ordering a CBC, BMP, and blood cultures can help identify the cause of the patient’s fever and tachycardia. These tests provide valuable information about the patient’s immune response, electrolyte balance, kidney function, and whether there is a bacterial infection.

Choice E rationale:

While sending sputum for culture and sensitivity could be helpful if a respiratory infection is suspected, the patient’s data does not strongly indicate a respiratory infection as the primary issue. Therefore, this test may not be the most immediate need.

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When performing postural drainage on a patient with chronic obstructive pulmonary disease (COPD), which approach should the nurse use?

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Explanation

Correct Answer is ["A","C","D"]

Explanation

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