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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is B
Explanation
A. Deep, rapid respirations (Kussmaul respirations) are more commonly associated with diabetic ketoacidosis, not hypoglycemia.
B. Tachycardia is a common response to hypoglycemia as the body attempts to compensate for low blood glucose levels.
C. Polyuria is more characteristic of hyperglycemia and diabetes mellitus, not hypoglycemia.
D. Dry flushed skin is not a typical manifestation of hypoglycemia. It may occur with hyperglycemia or dehydration.
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