Solutions
B. Client seated upright in bed or on a chair then leaning forward in sitting position then
flat on his back and on his abdomen CORRECT ANSWERS Situation - Richard has a
nursing diagnosis of ineffective airway clearance related to excessive secretions and is
at risk for infection because of retained secretions. Part of Nurse Mario's nursing care
plan is to loosen and remove excessive secretions in the airway.
MariolistenstoRichard'sbilateralsoundsandfindsthatcongestionisintheupperlobesofthe
lungs. The appropriate position to drain the anterior and posterior apical segments of
the lungs when Mario does percussion would be:
A. Client lying on his back then flat on his abdomen on Trendelenburg position
B. Client seated upright in bed or on a chair then leaning forward in sitting position then
flat on his back and on his abdomen
C. Client lying flat on his back and then flat on his abdomen
D. Client lying on his right then left side on Trendelenburg position
C. Amount of fluid intake of client before and after the procedure CORRECT ANSWERS
When documenting outcome of Richard's treatment Mario should include the following
in his recording EXCEPT:
A. Color, amount and consistency of sputum
B. Character of breath sounds and respiratory rate before and after procedure
C. Amount of fluid intake of client before and after the procedure
D. Significant changes in vital signs
B. Client can tolerate sitting and lying positions CORRECT ANSWERS Mario prepares
Richard for postural drainage and percussion. Which of the following is as pecial
consideration when doing the procedure?
A. Respiratory rate of 16 to 20 per minute
B. Client can tolerate sitting and lying positions
C. Client has no signs of infection
D. Time of last food and fluid intake of the client
D. Do a physical examination while asking the client relevant questions CORRECT
ANSWERS When doing an initial assessment, the best way for you to identify the
client's priority problemis to:
A. Interview the client for chief complaints and other symptoms
B. Talk to the relatives to gather data about history of illness
C. Do auscultation to check for chest congestion