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 ["B","C","E"]

Explanation

A. A back massage (A) can be soothing and may help with circulation, but it's not typically a priority immediately postoperative.
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 empower the client to actively participate in their comfort and recovery process.

C. Postoperative clients are at risk of developing respiratory complications such as atelectasis (partial lung collapse) due to shallow breathing. Coughing and deep breathing exercises help to expand lung volume, clear secretions, and prevent respiratory complications. It's important to encourage and assist the client in performing these exercises regularly.
D. Encouraging the client to turn every 4 hours helps prevent pressure ulcers and promotes good circulation, but turning might be more frequent depending on the surgery and the client's condition.
E. Pain management is crucial for postoperative comfort and recovery. Administering analgesics as needed helps to control pain effectively, which is essential for the client to participate in activities such as deep breathing, coughing, and moving, thereby reducing the risk of complications.

A. PaCO2 above 45 mm Hg B. HCO3 above 26 mEq/L C. PaO, below 70 mm Hg D. pH below 3.5

Correct Answer is D

Explanation

A. PaCO2 (partial pressure of carbon dioxide) reflects the respiratory component of acid-base balance. In metabolic acidosis, the respiratory system compensates by increasing ventilation to decrease PaCO2 (hyperventilation). Therefore, PaCO2 is typically below normal (less than 35-45 mm Hg) in metabolic acidosis, not above 45 mm Hg.
B. HCO3 (bicarbonate) is a buffer that helps regulate pH in the body. In metabolic acidosis, there is a primary decrease in HCO3 due to either increased acid production (e.g., lactic acidosis, ketoacidosis) or decreased acid elimination (e.g., renal failure). Therefore, HCO3 is typically below normal (< 22-26 mEq/L) in metabolic acidosis, not above 26 mEq/L.
C. PaO2 (partial pressure of oxygen) measures the oxygen level in the blood. It is not directly related to the diagnosis of metabolic acidosis. Low PaO2 levels may indicate respiratory dysfunction or impaired gas exchange but are not specific to metabolic acidosis.
D. pH below 7.35 indicates acidosis. In metabolic acidosis, the primary defect is a decrease in blood pH due to an excess of acids or a loss of bases. The pH typically decreases below the normal range of 7.35-7.45 in metabolic acidosis.

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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 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 ["B","C","E"]

Explanation

A nurse is reviewing the arterial blood gas (ABG) results of a client who the provider suspects has metabolic acidosis. Which of the following results should the nurse expect to see?

Correct Answer is D

Explanation

The nurse recognizes the need for client education when the client scheduled for a computed tomography (CT) states:

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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?

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A nurse is reviewing laboratory results for a client who is scheduled for surgery this morning. Which of the following results will cause the nurse to place a call to the surgical team?

A nurse is caring for a client who is postoperative and whose respirations are shallow and 9/min. Which of the following acid-based imbalances should the nurse identify the client as being at risk for developing initially?

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