A client returns to the unit after having a bronchoscopy. The client states "my throat is so dry. Can I have a glass of water?". How will the nurse respond?
"I will give you some ice chips instead of a drink of water".
"I have to assess your gag reflex before giving you any food or water".
"I will call the primary health care provider and request an order for food and water".
"Let's try having a small sip of water to see if you can swallow".
The Correct Answer is B
A. Offering ice chips, might seem like a safe alternative, but it still poses a risk if the gag reflex is not intact.
B. Assessing the gag reflex is crucial before offering food or fluids to ensure the client can protect their airway and swallow safely. This response prioritizes safety and is appropriate to ensure the client does not aspirate.
C. Calling the healthcare provider to request orders for food and water may be necessary if there are specific protocols or if the client's condition requires further assessment or interventions before oral intake can be resumed. However, this response does not address the immediate need for comfort and hydration.
D. This response involves assessing the client's ability to swallow directly. While it addresses the client's request for water, it may not be the safest initial approach without first assessing the client's readiness and ability to swallow safely.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. It is particularly sensitive to deficiencies in clotting factors, but it does not measure the deficiencies themselves
B. The activated partial thromboplastin time (aPTT) test measures the effectiveness of the intrinsic and common pathways of the coagulation cascade.
C. There is no need to skip breakfast or alter diet for an aPTT test. It is not affected by food intake or fasting status.
D. While aPTT is used to monitor heparin therapy, it is not typically used to monitor warfarin (a vitamin K antagonist) therapy. Warfarin therapy is usually monitored using the prothrombin time (PT) and international normalized ratio (INR) tests.
Correct Answer is A
Explanation
A. A potassium level of 2.9 mEq/L is below the normal range (typically 3.5-5.0 mEq/L). Abnormal potassium levels can affect cardiac function, leading to arrhythmias (irregular heartbeats), especially if the potassium level drops further or if there is rapid fluctuation. This is a critical finding that requires immediate attention from the surgical team to assess the client's cardiac status and determine if potassium replacement is needed before proceeding with surgery.
B. Creatinine levels are used to assess kidney function. A creatinine level of 1.2 mg/dL is within the normal range (typically 0.6-1.2 mg/dL). While kidney function is important to evaluate before surgery, this result is not immediately concerning enough to require an urgent call to the surgical team.
C. Hemoglobin levels are assessed to evaluate oxygen-carrying capacity of the blood. A hemoglobin level of 14.8 g/dL is within the normal range (typically 12-16 g/dL for women and 13-18 g/dL for men). This result indicates adequate oxygen-carrying capacity and does not require immediate communication with the surgical team.
D. Sodium levels are important for fluid balance and nerve function. A sodium level of 134 mEq/L is within the normal range (typically 135-145 mEq/L). While sodium levels should be monitored, this result is not critically abnormal and does not necessitate an urgent call to the surgical team.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.