A patient arrives in the emergency department with an attack of acute bronchiectasis. Chest auscultation reveals the presence of copious secretions. What intervention should the nurse prioritize in this patients care?

Correct Answer: C

Rationale: In acute bronchiectasis with copious secretions, postural chest drainage is the priority intervention, leveraging gravity to mobilize thick mucus from dilated bronchi, reducing obstruction and infection risk. This technique positioning the patient to drain specific lung segments (e.g., head-down for lower lobes) alleviates dyspnea and prevents atelectasis, a cornerstone of bronchiectasis management. Diuretics treat fluid overload, irrelevant to airway secretions. IV fluids may hydrate but don't directly thin bronchial mucus oral hydration or mucolytics are more apt. Pulmonary function testing assesses obstruction but doesn't clear secretions, delaying symptom relief. The nurse's focus on postural drainage, often paired with percussion, addresses the acute crisis's root mucus retention enhancing ventilation and supporting recovery in this chronic condition's exacerbation.

Correct Answer: A

Rationale: Perioperative nursing care encompasses the full surgical experience before, during, and after surgery ensuring comprehensive patient support across all phases. Preadmission testing, part of the preoperative phase, involves assessments like lab reviews but doesn't cover the entire perioperative scope. Care during the surgical procedure, or intraoperative phase, focuses on the operation itself, while the postanesthesia care unit (PACU) represents the postoperative phase, aiding recovery. Each of these is a segment of perioperative care, but only 'before, during, and after surgery' captures the complete definition. This holistic approach reduces risks like infection or complications by integrating preparation, intervention, and recovery. The nurse's explanation to the student highlights this broad responsibility, emphasizing continuity from preoperative education to postoperative monitoring, aligning with standards to optimize patient outcomes and safety throughout the surgical journey.

Correct Answer: A

Rationale: Correct diaphragmatic breathing is confirmed when hands on the rib cage borders touch as the chest wall contracts during exhalation. This reflects the diaphragm's upward movement, pushing air out, while inhalation separates fingers as the diaphragm descends, expanding the abdomen. Chest wall hand placement showing separation on contraction suggests shallow breathing, not diaphragmatic. Feeling upward diaphragm movement during inspiration or downward during expiration reverses normal mechanics diaphragm moves down to inhale, up to exhale. This tactile feedback, taught by the nurse, ensures deep, effective breaths, preventing atelectasis by maximizing lung expansion, a key postoperative recovery skill.

Correct Answer: A

Rationale: Notifying the operating suite of a latex allergy is most important, as latex is pervasive in surgical settings (gloves, tubes), and exposure risks anaphylaxis, requiring immediate room preparation with latex-free supplies. This preempts delays or emergencies, prioritizing safety. Documenting a bath, obtaining vital signs, or giving antibiotics are routine but secondary latex reaction prevention is urgent due to its acute, life-threatening potential. The nurse's action ensures a safe environment, aligning with allergy management protocols to protect the patient throughout surgery.

Correct Answer: B

Rationale: A coronary artery bypass graft, a major procedure, requires intensive care unit (ICU) monitoring immediately post-op due to prolonged anesthesia and risks like arrhythmias or bleeding. ICU provides advanced oversight (e.g., cardiac monitoring) beyond a medical-surgical unit's capacity. Ambulatory settings suit minor surgeries, not this complexity. The nurse's expectation ensures critical care, aligning with standards for high-risk postoperative recovery.