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 ["B","C","E","F","G"]

Explanation

The correct answer is choiceb. Identify the client using 2 client identifiers,c. Perform hand hygiene,e. Don gloves,f. Check the skin around the face, andg. Assess respiratory function.

Choice A rationale:

Determining if the client needs to go to the bathroom is not directly related to the immediate preparation for oxygen administration. However, it can be considered as part of overall patient comfort and care.

Choice B rationale:

Identifying the client using 2 client identifiers is crucial to ensure the correct patient is receiving the correct treatment, which is a standard safety protocol in healthcare settings.

Choice C rationale:

Performing hand hygiene is essential to prevent the spread of infection and maintain a sterile environment.

Choice D rationale:

Brushing the client’s teeth is not a necessary step before applying a simple face mask for oxygen administration. It is more related to general oral hygiene.

Choice E rationale:

Donning gloves is important to protect both the nurse and the patient from potential contamination and infection.

Choice F rationale:

Checking the skin around the face is important to ensure there are no existing sores or irritations that could be exacerbated by the mask.

Choice G rationale:

Assessing respiratory function is critical to determine the patient’s baseline respiratory status and to monitor the effectiveness of the oxygen therapy.

A. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus. B. Isolate the client from other clients, family, and healthcare workers not wearing proper personal protective equipment (PPE). C. Report the COVID-19 result to the local health department according to Center for Disease Control (CDC) guidelines. D. Counsel family members to monitor for illness symptoms for 2 weeks after last contact with patient.

Correct Answer is B

Explanation

Choice A rationale:

While teaching the client about infection prevention measures is important, it is not the most immediate priority in this situation. The client is already potentially contagious, and these measures may not be sufficient to prevent transmission if the client is not properly isolated.

It's crucial to remember that the client may be experiencing cognitive impairment due to illness, making it harder to fully comprehend and adhere to instructions.

Additionally, some clients may not have access to or be able to afford masks and hand sanitizer, potentially hindering compliance with these measures.

Choice B rationale:

Isolating the client is the most critical action to prevent the spread of COVID-19 to others. This includes separating the client from other patients, family members, and healthcare workers who are not wearing proper PPE.

PPE, such as gloves, gowns, masks, and eye protection, creates a barrier between the healthcare worker and the client, minimizing the risk of transmission via direct contact or droplets.

Proper isolation techniques include placing the client in a designated negative-pressure isolation room, if available, or designating a separate area within a multi-bed room.

It's essential to restrict the client's movement within the healthcare facility and limit visitors to essential personnel only.

Choice C rationale:

Reporting the COVID-19 result to the local health department is important for tracking and managing the spread of the virus; however, it is not the most immediate priority in this situation.

The priority is to prevent further transmission by isolating the client.

Choice D rationale:

Counseling family members to monitor for symptoms is important, but it is not the most immediate priority in this situation. The priority is to prevent transmission by isolating the client.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to set up the oxygen administration and apply the simple face mask. What should the nurse do before applying the face mask? Select all that apply.

Correct Answer is ["B","C","E","F","G"]

Explanation

A client presents to the emergency department with muscle aches, headache, fever, and describes a recent loss of taste and smell.The nurse obtains a nasal swab for COVID-19 testing. Which action is most important for the nurse to take?

Correct Answer is B

Explanation

A client presents to the emergency department with muscle aches, headache, fever, and describes a recent loss of taste and smell.The nurse obtains a nasal swab for COVID-19 testing. Which action is most important for the nurse to take?

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