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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A: Repositioning the client at least every 2 hours is crucial for preventing further pressure ulcers and promoting healing. Regular repositioning helps to relieve pressure on vulnerable areas, improve circulation, and prevent skin breakdown.
B: Cleaning the wound with hydrogen peroxide solution is not recommended. Hydrogen peroxide can damage healthy tissue and delay wound healing. Saline or a gentle wound cleanser should be used instead.
C: Massaging reddened areas with dressing changes is not advisable. Massaging can cause further damage to already compromised skin and tissues. Gentle handling and avoiding pressure on these areas are more appropriate.
D: Applying a heat lamp twice a day is not a standard intervention for pressure ulcers. Heat lamps can cause burns and further damage to the skin. Maintaining a moist wound environment and using appropriate dressings are better practices.
Correct Answer is D
Explanation
A: Degenerative joint changes can affect mobility and overall health but do not directly contribute to aspiration pneumonia.
B: Decreased gastric secretions can affect digestion but are not a primary factor in the development of aspiration pneumonia.
C: A decreased sense of smell can affect appetite and food intake but does not directly lead to aspiration pneumonia.
D: A diminished cough reflex is a significant age-related change that can contribute to the development of aspiration pneumonia. The cough reflex helps clear the airway of food, liquid, and other foreign materials. When this reflex is diminished, the risk of aspiration and subsequent pneumonia increases.
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