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".

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Encouraging adequate fluid intake is important postoperatively to maintain hydration and support normal physiological functions. However, the amount of fluid intake should be within the client's tolerance and as prescribed by the healthcare provider. It helps prevent complications such as dehydration and promotes circulation, which is beneficial for wound healing.

B. While some rest and limited mobility are initially recommended after knee replacement surgery to allow for healing and to prevent complications, prolonged bed rest for 5-7 days is not typically necessary or recommended. Early mobilization and gradual increase in activity are encouraged to prevent complications such as deep vein thrombosis and to promote recovery.
C. Placing a pillow directly under the knee is not recommended as it can lead to decreased range of motion and potential contractures.
D. Cold therapy, such as applying cool compresses, is often used to reduce swelling and pain in the initial postoperative period. It can help manage pain and discomfort and promote comfort for the client.

A. Give the client aback massage. B. Teach the client relaxation techniques. C. Assist the client to cough and deep breathe ev D. Encourage the client to turn every 4 hr. E. Administer PRN analgesics as needed.

Correct Answer is ["A","B","C","E"]

Explanation

A. Postoperative patients often experience muscle tension and discomfort due to lying in one position for an extended period. A gentle back massage can help relieve muscle stiffness, promote relaxation, and improve circulation. It is a non-invasive comfort measure that can enhance the client's overall well- being.
B. Teaching relaxation techniques such as deep breathing exercises, guided imagery, or progressive muscle relaxation can help the client manage pain, reduce anxiety, and promote faster recovery. These techniques are beneficial postoperatively as they encourage relaxation and improve overall comfort.
C. Postoperative clients are at risk of developing respiratory complications such as atelectasis (partial lung collapse) or pneumonia due to shallow breathing or inadequate lung expansion. Coughing and deep breathing exercises help to clear secretions, improve lung function, and prevent respiratory complications. It is typically recommended to perform these exercises every hour to maintain lung expansion and prevent complications.
D. Encouraging the client to turn every 2 hours (D), not every 4 hours, is essential to prevent pressure ulcers and promote circulation.
E. Postoperative pain management is essential for the client's comfort and recovery. Pain can interfere with the client's ability to cough, deep breathe, and move effectively, which may increase the risk of complications. Administering analgesics as needed helps to control pain, improve overall comfort, and promote participation in necessary activities such as coughing, deep breathing, and turning.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client 8 hr postoperative following a total knee replacement. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is planning care for a client who is 4 hr postoperative. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

Correct Answer is ["A","B","C","E"]

Explanation

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A nurse is planning care for a client who is 4 hr postoperative. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

A nurse is reviewing the laboratory values of a client who has respiratory acidosis. Which of the following findings should the nurse expect?