A nurse is performing chest percussion therapy on a client. Which of the following actions should the nurse take?

Correct Answer: B

Rationale: In chest percussion therapy, the correct action for the nurse is to listen for a hollow sound when performing the technique. This is because a hollow sound indicates that the therapy is being performed effectively, helping to loosen and mobilize secretions in the lungs. By listening for this sound, the nurse can ensure that the therapy is being carried out correctly and benefiting the client. Option A is incorrect because there is no set frequency for performing chest percussion therapy. The frequency should be based on the client's individual needs and the healthcare provider's recommendations. Option C is incorrect because using flat hands to perform chest percussion therapy is not ideal. Cupped hands are typically used to create a proper percussion effect on the chest. Option D is incorrect because chest percussion therapy should be applied over the muscles of the back and not directly over the client's ribs to prevent discomfort or injury. Educationally, it is important for nurses to understand the correct techniques and principles of chest percussion therapy to provide safe and effective care to clients with respiratory issues. Listening for the correct sound helps ensure the therapy is beneficial, while avoiding improper techniques can prevent harm to the client.

Correct Answer: B

Rationale: Rationale: The correct answer is B) Lose weight if you are overweight. This is the most appropriate intervention because excess weight can contribute to the development or exacerbation of sleep apnea. By losing weight, the client can reduce the amount of soft tissue in the throat area that may block the airway during sleep, improving breathing patterns and reducing apnea episodes. Option A) Sleep on your back to maintain an open airway is incorrect as sleeping on the back can actually worsen sleep apnea by causing the tongue and soft tissues to collapse into the airway, leading to obstruction. Option C) Avoid using CPAP if symptoms improve is incorrect because CPAP (Continuous Positive Airway Pressure) is a common and effective treatment for sleep apnea. It helps keep the airway open during sleep by delivering a continuous flow of air through a mask. Option D) Limit fluid intake before bedtime is also incorrect as it may help reduce the frequency of nighttime awakenings to urinate, but it does not directly address the underlying issue of sleep apnea. In an educational context, teaching clients about the relationship between weight and sleep apnea is crucial. By understanding how weight can impact their condition, clients can make informed lifestyle changes to improve their symptoms and overall health. It is important for nurses to provide evidence-based education to empower clients in managing their sleep apnea effectively.

Correct Answer: C

Rationale: In this scenario, the nurse's priority action should be option C: assess the client's respiratory status and oxygen saturation. This is the correct answer because when a client with emphysema on oxygen therapy reports increasing shortness of breath, it is crucial to first assess their current respiratory status and oxygen saturation levels. These assessments provide immediate information about the client's oxygenation status and help the nurse determine the appropriate next steps in care. Option A, increasing the oxygen flow rate to 4 L/min, is not the priority action because changing the oxygen flow without assessing the client's status can be potentially harmful. It is important to gather data before making any adjustments to the oxygen therapy. Option B, notifying the healthcare provider immediately, is also not the priority at this moment. While it is essential to involve the healthcare provider in the client's care, assessing the client's condition should come first to provide timely and appropriate interventions. Option D, positioning the client in high Fowler's position, may help improve ventilation but does not address the immediate need to assess the client's respiratory status and oxygen saturation levels. In an educational context, this question highlights the significance of prioritizing assessments in nursing care. It reinforces the importance of data collection and critical thinking in making clinical decisions. Understanding the rationale behind prioritizing actions based on assessment findings is crucial for safe and effective nursing practice, especially in situations where prompt interventions are necessary to ensure patient safety and well-being.

Correct Answer: B

Rationale: In the context of a client with COPD being prescribed tiotropium (Spiriva), option B, "This medication is used for long-term management, not quick relief," is the correct answer. This is because tiotropium is a long-acting bronchodilator that helps to manage COPD symptoms over time by improving lung function and reducing exacerbations. It is not meant for immediate relief of symptoms during exacerbations, as stated in option A. Option C, "Avoid eating grapefruit while taking this medication," is incorrect as there is no known interaction between tiotropium and grapefruit. Option D, "Take the medication with food to prevent stomach upset," is also incorrect as tiotropium is typically taken on an empty stomach. In an educational context, it is crucial for nurses to understand the rationale behind medication administration to provide effective patient education. By emphasizing that tiotropium is a long-term management medication, nurses can ensure that patients use it correctly to achieve optimal therapeutic outcomes in the management of COPD. This knowledge helps in promoting patient adherence and self-management in the long-term care of COPD.

Correct Answer: B

Rationale: The correct answer is B) Prepare the client for a thoracentesis. In the context of a client with pleural effusion experiencing severe shortness of breath, a thoracentesis is the priority intervention to remove the accumulated fluid from the pleural space, relieving pressure on the lungs and improving oxygenation. This procedure can rapidly improve the client's breathing and oxygen levels, addressing the immediate respiratory distress. Option A) Position the client on the unaffected side may provide some comfort but does not address the underlying cause of the shortness of breath, which is the pleural effusion compromising lung expansion. Option C) Administer prescribed diuretics may be part of the treatment plan for managing pleural effusion in the long term by reducing fluid retention, but it is not the immediate priority in a client experiencing severe respiratory distress. Option D) Encouraging deep breathing exercises is not appropriate when the client is in severe respiratory distress due to pleural effusion. The priority is to relieve the pressure on the lungs through thoracentesis before focusing on breathing exercises. In an educational context, understanding the priority interventions for clients with respiratory conditions like pleural effusion is crucial for nurses to provide timely and effective care, especially in acute situations where respiratory compromise can quickly escalate. This question highlights the importance of critical thinking and prioritization in nursing practice, emphasizing the significance of addressing the root cause of respiratory distress to ensure optimal patient outcomes.