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.

Answer and Explanation

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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Correct Answer is B

Explanation

A. Blood cultures are important in the diagnostic workup for bacterial meningitis, but the priority is to obtain cerebrospinal fluid through a lumbar puncture for definitive diagnosis.

B. A lumbar puncture is a priority in suspected bacterial meningitis to assess the cerebrospinal fluid for signs of infection and to guide appropriate treatment.

C. Administering an intravenous antibiotic is an important intervention, but the lumbar puncture takes precedence for confirming the diagnosis.

D. Placing the child in isolation is important for preventing the potential spread of infection, but the immediate diagnostic priority is the lumbar puncture.

A. Body weight B. Blood pressure C. Skin integrity D. Respiratory rate E. Respiratory rate

Correct Answer is A

Explanation

A. Body weight is the most reliable indicator of fluid loss in an infant. Changes in weight can reflect changes in fluid balance more accurately than other parameters.
B. Blood pressure may be affected by severe dehydration, but it is not as sensitive or specific as changes in body weight.
C. Skin integrity can be affected by dehydration, but it is not as direct a measure of fluid loss as changes in body weight.
D. Respiratory rate can be influenced by various factors, including respiratory distress, and is not as specific to fluid loss as changes in body weight.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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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?