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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
These findings indicate improvements in overall status:
- Alert and oriented: No neurological impairment.
- Clear breath sounds: No signs of respiratory compromise.
- Pedal pulses and warm feet: Circulation is restored.
- Reduced pain: Indicates effective pain management.
Correct Answer is A
Explanation
A. Hypernatremia: Excessive fluid loss through sweat, combined with insufficient fluid intake, can lead to hypernatremia (elevated sodium levels), often seen in heat exhaustion.
B. Hypocalcemia: Calcium levels are not typically affected by heat exhaustion.
C. Hyperkalemia: Potassium levels usually decrease due to sweating, not increase.
D. Hyperphosphatemia: Phosphate levels are not significantly altered in heat exhaustion.
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