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.

Answer and Explanation

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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Correct Answer is C

Explanation

The correct answer is C.

A: Consulting a dietitian is a beneficial order for a patient with a pressure ulcer. Proper nutrition, especially adequate protein intake, is crucial for wound healing. A dietitian can help ensure the patient receives the necessary nutrients to support tissue repair and recovery.

B: Applying a hydrogel dressing is appropriate for a clean, granulating Stage II pressure ulcer. Hydrogel dressings maintain a moist wound environment, which promotes healing and provides pain relief. They are suitable for wounds with minimal to moderate exudate.

C: Cleaning the wound with hydrogen peroxide is not recommended for a healing pressure ulcer. Hydrogen peroxide can damage healthy granulating tissue and delay the healing process. It is better to use saline or a wound cleanser that does not harm the new tissue.

D: Using a low-air-loss therapy unit is beneficial for patients with pressure ulcers. These units help reduce pressure on the skin, improve circulation, and prevent further skin breakdown. They are an effective part of pressure ulcer management.

A. Post a “No Smoking” sign in the home. B. Attach oxygen containers to a fixed object. C. Store spare oxygen tanks in a closet. D. Notify the fire department that oxygen is used in the home. E. Ensure oxygen tubing is no longer than 60 feet in length.

Correct Answer is A

Explanation

A: Posting a “No Smoking” sign in the home is crucial for safety when using home oxygen. Oxygen can accelerate combustion, making even a small spark potentially dangerous. This sign serves as a constant reminder to avoid smoking and open flames near the oxygen source.

B: Attaching oxygen containers to a fixed object is important to prevent them from falling over and potentially causing damage or leaks. However, this is not the most critical instruction compared to ensuring no smoking around oxygen.

C: Storing spare oxygen tanks in a closet is not recommended. Oxygen tanks should be stored in a well-ventilated area to prevent the buildup of oxygen, which could increase the risk of fire.

D: Notifying the fire department that oxygen is used in the home is a good safety measure. It ensures that emergency responders are aware of the presence of oxygen, which can affect their approach in case of a fire. However, it is not as immediate a safety measure as posting a “No Smoking” sign.

E: Ensuring oxygen tubing is no longer than 60 feet in length is important to maintain adequate oxygen flow and prevent tripping hazards. However, this is a secondary safety measure compared to preventing smoking around oxygen.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with a healing Stage II pressure ulcer. The wound is clean and granulating. Which health care provider’s order will the nurse question?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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