Postural drainage with percussion and vibration is ordered twice daily for a patient with chronic bronchitis. Which intervention should the nurse include in the plan of care?

Correct Answer: B

Rationale: Correct Answer: B Rationale: Maintaining the patient in the lateral position for 20 minutes after postural drainage with percussion and vibration helps to facilitate drainage of secretions from the affected lung segments. This position helps to target specific lung segments and allows gravity to assist in moving secretions towards larger airways for easier expectoration. Incorrect Choices: A: Scheduling the procedure 1 hour after the patient eats is not necessary for postural drainage with percussion and vibration. It is more important to maintain the patient in the proper position for effective drainage. C: Giving albuterol before therapy is not directly related to postural drainage with percussion and vibration. Albuterol is a bronchodilator that may be prescribed for bronchospasm but is not directly related to postural drainage. D: Performing percussion before assisting the patient to the drainage position is incorrect. Percussion should be performed after the patient is in the appropriate position to facilitate secretion movement.

Correct Answer: B

Rationale: The correct answer is B: Notify the healthcare provider. This is the priority intervention because postoperative nausea could indicate a serious complication that requires immediate attention from the healthcare provider. Administering antiemetics (A) may help relieve symptoms but does not address the underlying cause. Administering oral rehydration solutions (C) may be beneficial for dehydration but should not be the priority without knowing the cause of nausea. Administering a vasodilator (D) is not indicated for nausea and could potentially worsen the patient's condition.

Correct Answer: B

Rationale: The correct answer is B: Administer glucose for hypoglycemia. In a patient with a history of diabetes experiencing dizziness and lightheadedness, the priority action is to address hypoglycemia, which can be life-threatening if left untreated. Administering glucose will help raise the blood sugar levels quickly and resolve the symptoms. Administering insulin (choices A and C) would lower blood sugar levels further, worsening the symptoms. Choice D, administering glucose for hypoglycemia, is incorrect because giving additional glucose to a patient already experiencing hypoglycemia can lead to rebound hypoglycemia. Thus, the priority is to treat hypoglycemia promptly with glucose.

Correct Answer: B

Rationale: The correct answer is B: Administer IV fluids. In a patient with COPD experiencing shortness of breath and fatigue, priority action is to address potential dehydration which can worsen symptoms. IV fluids can help improve hydration status, support oxygen delivery, and decrease respiratory distress. Administering pain relief (choices A and C) is not the priority as the main concern is respiratory distress. Administering a nebulized bronchodilator (choice D) can be beneficial but addressing dehydration takes precedence to optimize respiratory function.

Correct Answer: D

Rationale: In this scenario, option D, "The partial pressure of oxygen in arterial blood (PaO₂) is 59 mm Hg," requires immediate action. A PaO₂ of 59 mm Hg indicates severe hypoxemia, which means there is a dangerously low level of oxygen in the blood. Immediate intervention is necessary to improve oxygenation and prevent potential complications like tissue damage or organ failure. Option A, with a bicarbonate level of 31 mEq/L, may indicate metabolic alkalosis but does not pose an immediate threat to the patient's life. Option B, an arterial oxygen saturation (SaO₂) of 92%, while slightly lower than normal, does not signify an urgent issue requiring immediate action. Option C, a partial pressure of CO₂ in arterial blood (PaCO₂) of 31 mm Hg, is within normal range and does not indicate immediate danger to the patient. Understanding ABG values is crucial for nurses to assess a patient's respiratory and metabolic status accurately. Recognizing abnormal ABG results and their implications allows timely interventions to optimize patient outcomes. Nurses must be adept at interpreting ABG values to provide prompt and effective care, especially in critical situations like severe hypoxemia.