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
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Correct Answer is B
Explanation
A. RSV is primarily spread through respiratory droplets, so allowing the toddler to play in the common room may expose other children to the virus. The child should be placed in a private room.
B. Keeping the thermometer in the toddler's room allows for monitoring of the child's
temperature without the need to bring the thermometer to different areas, helping to prevent the potential spread of the virus.
C. Airborne precautions are not necessary for RSV. Standard precautions, including contact and droplet precautions, are sufficient.
D. Negative air pressure rooms are typically used for airborne infections such as tuberculosis, not for respiratory syncytial virus.
Correct Answer is A
Explanation
A. Tugging or pulling at the ear is a common sign in children with otitis media and may indicate ear pain.
B. Pain when manipulating the affected earlobe is expected in otitis media due to inflammation and infection of the middle ear.
C. Erythema and edema of the affected ear are typical findings in otitis media, indicating inflammation.
D. Clear drainage is not a typical finding in otitis media. Drainage, if present, is more likely to be purulent or serosanguinous.
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