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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Correct Answer is C
Explanation
A. Ignoring temper tantrums may not be effective in all situations. Some toddlers may escalate their behavior if they feel ignored.
B. Explicitly telling the child that temper tantrums are not acceptable may not be as effective in managing the behavior. Toddlers may not fully understand or respond well to verbal reasoning.
C. Distracting the child with a different activity, such as playing a game, can redirect their attention and help diffuse the situation.
D. Physical restraint is not an appropriate or effective method for managing temper tantrums. It can lead to increased resistance and may cause harm to the child.
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.
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