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 B
Explanation
Choice A rationale
Serum blood glucose level is not directly related to the presence of purulent drainage at a wound site. While blood glucose levels can affect wound healing, they do not provide specific information about the presence of infection.
Choice B rationale
Culture for sensitive organisms is the most appropriate laboratory value to note when purulent drainage is observed. This test helps identify the specific bacteria causing the infection and determines the most effective antibiotics for treatment.
Choice C rationale
C-reactive protein (CRP) level is a marker of inflammation and can indicate the presence of an infection, but it does not provide specific information about the bacteria causing the infection.
Choice D rationale
Blood pH level is not directly related to the presence of purulent drainage at a wound site. While blood pH can be affected by severe infections, it is not a specific indicator of wound infection.
Correct Answer is C
Explanation
Choice A rationale
Restricting fluids is not a primary limitation for clients with Crohn’s disease. Adequate hydration is important for overall health and managing symptoms.
Choice B rationale
Limiting foods high in calcium and iron is not typically recommended for Crohn’s disease. These nutrients are important for maintaining bone health and preventing anemia, which can be concerns for individuals with Crohn’s disease.
Choice C rationale
An elimination diet can help identify trigger foods that may exacerbate symptoms of Crohn’s disease. This approach involves removing certain foods from the diet and gradually reintroducing them to determine which foods cause symptoms.
Choice D rationale
Avoiding gluten is not necessary for all individuals with Crohn’s disease. While some may benefit from a gluten-free diet, it is not a universal recommendation for managing the condition.