A nurse is assisting in the care of a client following a tonsillectomy who is alert and has an SpO2 of 93% on room air. Which of the following actions should the nurse take?

Obtain the client's peak expiratory flow volume.

Encourage the client to cough.

Place the client in a semi-Fowler's position.

Encourage the client to use a straw to sip cool liquids.

Answer and Explanation

The Correct Answer is C

A. Obtain the client's peak expiratory flow volume: This is unnecessary in this context and not a routine assessment post-tonsillectomy.
B. Encourage the client to cough: Coughing can irritate the surgical site and increase the risk of bleeding.
C. Place the client in a semi-Fowler's position. Semi-Fowler's position promotes optimal airway clearance and reduces the risk of aspiration or airway obstruction.
D. Encourage the client to use a straw to sip cool liquids: Straws are contraindicated because the suction action can disrupt the surgical site and cause bleeding.

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Correct Answer is B,E,C,A,D

Explanation

Correct order:

Perform hand hygiene.
Remove the dressing and tape from the venipuncture site.
Clamp the IV tubing.
Apply pressure to the venipuncture site with sterile gauze.
Withdraw the catheter from the client's vein.

Rationale:

Hand hygiene is the first step to prevent infection before touching any equipment or the client.
Removing the dressing and tape is done after hand hygiene to expose the IV insertion site, preparing it for removal.
Clamping the IV tubing helps stop the infusion and prevents blood from flowing out when the catheter is removed.
Applying pressure with sterile gauze helps to prevent bleeding and hematoma formation after the catheter is removed.
Withdrawing the catheter should be the final step to complete the procedure.

A. Apply five drops of developer to each smear. B. Use the same part of stool for each sample. C. Ensure the sample contains no urine. D. Wait 10 min before applying the developing solution.

Correct Answer is C

Explanation

A. Apply five drops of developer to each smear: Typically, two drops of developer are applied per sample, not five. Applying excess developer may dilute the reaction and yield unreliable results.
B. Use the same part of stool for each sample: Samples should be taken from different parts of the stool to ensure accuracy and detect localized bleeding.
C. Ensure the sample contains no urine: Urine contamination can interfere with test results, leading to inaccurate findings. The client should collect a clean stool sample.
D. Wait 10 min before applying the developing solution: The developing solution should be applied immediately after placing the stool sample on the test card to prevent errors in interpretation.

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A nurse is assisting in the care of a client following a tonsillectomy who is alert and has an SpO2 of 93% on room air. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to discontinue a client's intravenous infusion. Identify the sequence the nurse should follow to remove the IV catheter. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is B,E,C,A,D

Explanation

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Correct Answer is C

Explanation

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