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 C
Explanation
A. Threatening the child with a shot may create anxiety and fear, making cooperation even more challenging.
B. Hiding medication in food without the child's knowledge can lead to mistrust and may not be safe, as the child may not consume the entire dose.
C. Telling the child that the medication is candy is a strategy that may increase the likelihood of the child taking the medication willingly. However, it is important to ensure that the child understands the importance of taking the medication and that it is not actually candy.
D. Offering a choice of taking the medication with juice or water provides some control to the child, but it may not address the resistance to taking the medication itself. The child may still refuse regardless of the choice.
Correct Answer is B
Explanation
A. While play in the playroom is generally beneficial, providing a specific activity related to the child's distress from the insulin injection is more targeted.
B. Offering a needleless syringe and a doll allows the child to engage in play that mimics the experience of receiving an injection. This can help the child gain a sense of control and understanding of the procedure.
C. A video game may serve as a distraction, but it may not specifically address the child's distress related to the insulin injection.
D. A storybook about a child who has diabetes may provide education and reassurance, but it may not actively engage the child in a therapeutic play activity related to the injection experience.
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