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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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 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.
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