A nurse is caring for a client who is postoperative and has a peripheral IV, and is requesting ice chips. Which of the following actions should the nurse take?
Lower the head of the client’s bed.
Check the client’s gag reflex.
Remove the client’s peripheral IV.
Check the client for bladder distention.
The Correct Answer is B
A: Lowering the head of the client’s bed is not appropriate in this situation. It does not address the safety concern related to swallowing.
B: Checking the client’s gag reflex is the correct action. This ensures that the client can safely swallow ice chips without the risk of aspiration.
C: Removing the client’s peripheral IV is not related to the request for ice chips and is unnecessary unless there is a specific reason to do so.
D: Checking the client for bladder distention is not relevant to the request for ice chips and does not address the immediate concern of safe swallowing.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A: Proceeding to measure the oral temperature immediately after the client has eaten ice chips is not appropriate. The cold temperature can affect the accuracy of the reading.
B: Documenting that the nurse was unable to measure the client’s temperature is unnecessary. The nurse can take steps to ensure an accurate measurement by waiting.
C: Providing the client a sip of warm water and waiting 5 minutes is not sufficient to counteract the effect of the ice chips on the oral temperature reading.
D: Waiting 30 minutes before measuring the oral temperature is the correct action. This allows time for the oral cavity to return to its normal temperature, ensuring an accurate reading.
Correct Answer is C
Explanation
A: Keeping a fluorescent ceiling light on at night can be too bright and disrupt sleep. A nightlight is a better option for safety without disturbing sleep.
B: Keeping the walker at the end of the bed is not ideal. The walker should be within easy reach to prevent falls when getting out of bed.
C: Placing a bath seat in the shower is a good safety measure. It provides stability and reduces the risk of slipping and falling while bathing.
D: Placing an area rug at the entry of the bathroom can be a tripping hazard. It is better to use non-slip mats that are securely placed.
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