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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Rovsing's sign is a rebound tenderness felt in the right lower quadrant when the left lower quadrant is palpated. It may be positive in acute appendicitis but is not indicative of perforation.
B. A low-grade fever is common in acute appendicitis but may not necessarily indicate perforation.
C. A sudden decrease in abdominal pain may indicate perforation, but it is not a definitive sign.
Perforation can lead to a temporary relief of pain as the irritants spread throughout the peritoneum.
D. A flaccid abdomen (soft and lacking muscular tension) can be a sign of peritonitis, which may occur due to perforation of the appendix. It suggests irritation of the peritoneum and is a more significant concern than a localized infection.
Correct Answer is C
Explanation
A. The described behaviors, such as sitting quietly and turning away, may suggest the toddler is seeking comfort and self-soothing, which can be indicative of developing autonomy rather than anxiety.
B. Resentment toward the mother is a less likely interpretation of these behaviors, especially considering the age of the toddler.
C. Developing autonomy is a common developmental stage around this age. Toddlers begin to explore their independence and may engage in self-soothing behaviors.
D. Regression is a return to an earlier developmental stage. The behaviors described are more consistent with the development of autonomy rather than regression.
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