A nurse in a PACU is admitting a client who is postoperative following a tonsillectomy.
Which of the following actions should the nurse plan to take to prevent aspiration?
Suction the nasopharynx as needed.
Withhold fluids until the client demonstrates a gag reflex.
Perform chest physiotherapy.
Place a bedside humidifier at the head of the client's bed.
The Correct Answer is B
A. Suctioning the nasopharynx as needed can help maintain airway patency but does not directly prevent aspiration during the recovery period.
B. Withholding fluids until the client demonstrates a gag reflex is a standard precaution to prevent aspiration, particularly in the immediate postoperative period.
C. Chest physiotherapy is not specifically indicated for preventing aspiration in the post- tonsillectomy period.
D. Placing a bedside humidifier at the head of the client's bed is not a specific intervention for preventing aspiration after tonsillectomy. Monitoring the client's ability to swallow and the return of the gag reflex is more relevant.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Obtaining a detailed history is an appropriate first step in assessing the nature of the bruises. This can help determine if the bruises are due to accidental injuries or if there are concerns for possible abuse.
B. Separating the child from the parents without further assessment may not be justified and could create unnecessary distress for the child and family.
C. Involving a psychiatrist without a clear understanding of the situation may not be the most immediate and necessary action.
D. Reporting suspected abuse to the authorities is a crucial step if abuse is suspected, but obtaining a detailed history is important to gather information for a comprehensive assessment.
Correct Answer is D
Explanation
A. Injecting insulin at a 90-degree angle is a common technique for subcutaneous insulin injections.
B. Rotating injection sites is important to prevent lipodystrophy and ensure proper absorption.
C. Insulin should be injected into areas with adipose tissue, such as the abdomen, thighs, or buttocks.
D. Aspiration is not recommended before insulin injections. Aspiration may increase the risk of injecting the insulin into a blood vessel, leading to erratic absorption and potential
hypoglycemia. The current practice is to inject insulin subcutaneously without aspiration.
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