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 ["300"]
Explanation
To calculate the volume of IV fluids infused from 0330 to 0600, you would determine the number of hours that have passed.
From 0330 to 0600 is 2.5 hours. Since the IV is infusing at 120 mL/hr, you would multiply the infusion rate by the number of hours. So, 120 mL/hr * 2.5 hours = 300 mL.
Therefore, the nurse should record 300 mL of IV fluids on the intake record at 0600.
Correct Answer is A
Explanation
A. Metformin is an oral antidiabetic medication commonly used to manage type 2 diabetes mellitus. It can cause a rare but serious side effect called lactic acidosis, especially in situations where there is impaired kidney function or when the drug interacts with contrast dye used in procedures like cardiac catheterization.
B. Carvedilol is a beta-blocker used to manage hypertension and heart failure. It does not have a significant interaction with contrast dye that would increase the risk of AKI.
C. Atorvastatin is a statin medication used to lower cholesterol levels. It does not interact with contrast dye in a way that increases the risk of AKI.
D. Nitroglycerin is a vasodilator used to relieve angina symptoms. It does not interact with contrast dye in a way that increases the risk of AKI.
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