When performing postural drainage on a client with chronic obstructive pulmonary disease (COPD), which approach should the nurse use?
Explain that the client may be placed in five positions.
Perform the drainage immediately after meals.
Obtain an arterial blood gas (ABG) prior to the procedure.
Instruct the client to breathe shallow and fast.
The Correct Answer is A
Choice A rationale
Postural drainage involves placing the client in various positions to facilitate the drainage of secretions from different parts of the lungs. Typically, the client may be placed in five positions: head down, prone, right and left lateral, and sitting upright.
Choice B rationale
Performing postural drainage immediately after meals is not recommended as it can cause nausea, vomiting, and aspiration. It is best to perform the procedure before meals.
Choice C rationale
Obtaining an arterial blood gas (ABG) prior to the procedure is not a standard requirement for postural drainage. ABGs are typically obtained to assess the client’s respiratory status but are not necessary for the procedure itself.
Choice D rationale
Instructing the client to breathe shallow and fast is not appropriate for postural drainage. The client should be encouraged to breathe slowly and deeply to help keep the airways open and facilitate the drainage of secretions.
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Correct Answer is A
Explanation
Choice A rationale
Respiratory acidosis is characterized by elevated levels of carbon dioxide (CO2) in the blood due to impaired ventilation. This accumulation of CO2 leads to a decrease in blood pH, making it more acidic.
Choice B rationale
Hyperventilation leads to a rapid elimination of CO2, which would result in respiratory alkalosis, not acidosis. Therefore, this choice does not support the pathophysiological process of respiratory acidosis.
Choice C rationale
Blood oxygen levels stimulating the respiratory rate is a compensatory mechanism for hypoxemia but does not directly cause respiratory acidosis. This process is more related to respiratory alkalosis.
Choice D rationale
The kidneys do play a role in acid-base balance, but they primarily eliminate acids other than CO2. They do not significantly convert CO2 for elimination, making this choice incorrect.
Correct Answer is B
Explanation
Choice A rationale
Teaching anxiety reduction methods for feelings of suffocation is important but not the most immediate action needed to address the client’s respiratory symptoms.
Choice B rationale
Increasing the daily intake of oral fluids to liquefy secretions is the most important action for the nurse to instruct the client about self-care. This helps to thin the mucus, making it easier to expectorate and improving breathing.
Choice C rationale
Calling the clinic if undesirable side effects of medications occur is important but not the most immediate action needed to address the client’s respiratory symptoms.
Choice D rationale
Avoiding crowded enclosed areas to reduce pathogen exposure is important but not the most immediate action needed to address the client’s respiratory symptoms.