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A nurse is caring for a client who is recovering from a bronchoscopy. Select the area the nurse should assess before giving the client ice chips or fluids. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Answer and Explanation

The Correct Answer is "{\"xRanges\":[33.882846916299556,42.693419603524234],\"yRanges\":[29.535864978902953,37.9746835443038]}"

A. Throat/Pharynx area: The gag reflex must be checked before giving fluids. Anesthetics used during bronchoscopy suppress the gag and cough reflex, which places the client at high risk of aspiration. Assessing the throat for return of reflexes ensures safe swallowing.

B. Head/Brain area: Assessing the brain is not necessary prior to resuming oral intake after bronchoscopy. Neurological function is important overall, but it does not determine whether the swallowing reflex has returned and if the client can safely manage oral fluids.

C. Mouth/Lips: Examining the lips or oral cavity may reveal dryness, bleeding, or trauma, but it does not determine readiness for fluids. The risk of aspiration persists unless gag reflex recovery is confirmed.

D. Chest/Lungs area: Assessing lung sounds is important for evaluating complications such as bronchospasm or pneumothorax, but this does not confirm readiness for oral intake. Aspiration risk remains the main concern until gag reflex recovery is established.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

Rationale for correct choices:

Safety: The client has an unsteady gait, dizziness on standing, ecchymosis in multiple healing stages, and abrasions, all of which raise concerns for recurrent falls or possible neglect. Ensuring the client’s immediate safety is the top priority before addressing other needs.
Notify Adult Protective Services: Scattered ecchymoses in different healing stages, poor hygiene, and possible neglect warrant a report to APS for further investigation to ensure the client’s protection.

Rationale for incorrect choices:

Hygiene: While poor hygiene, lice infestation, and odor are evident, these concerns are not immediately life-threatening compared to the safety risks of falls and potential abuse or neglect. They can be addressed after the client is safe and protected.
Nutrition: No clear evidence of malnutrition is provided, though decreased skin turgor suggests possible dehydration. However, nutrition needs are a lower priority than immediate safety concerns related to falls and potential abuse.
Arrange for dietary consult: This intervention would be appropriate later for long-term care planning, but it does not address the client’s most urgent risk factors.
Consult with social services for support: Social services may help coordinate resources, but urgent reporting to APS is needed first because of suspected neglect and abuse indicators.

A. Insert an indwelling urinary catheter. B. Use an alcohol-free barrier product. C. Reposition the client every 4 hr. D. Massage the skin over bony prominences.

Correct Answer is B

Explanation

A. Insert an indwelling urinary catheter: Indwelling catheters increase the risk of urinary tract infections and are not recommended solely for immobility. Managing incontinence with skin care and barrier products is safer for preserving skin integrity.

B. Use an alcohol-free barrier product: Alcohol-free barrier products protect the skin from moisture, friction, and irritation without causing dryness. This helps maintain skin integrity, especially in clients who are immobile and at high risk for breakdown.

C. Reposition the client every 4 hr: Immobile clients should be repositioned at least every 2 hours, not every 4. Prolonged pressure over bony areas can rapidly lead to pressure injuries if turning is delayed.

D. Massage the skin over bony prominences: Massaging over bony prominences can damage fragile tissue and worsen the risk of pressure injury. Instead, gentle repositioning and cushioning should be used to protect the skin.

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A nurse is caring for a client who is recovering from a bronchoscopy. Select the area the nurse should assess before giving the client ice chips or fluids. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an older adult client being admitted into a long-term care facility. Exhibits Complete the following sentence by using the list of options. The nurse should address the client's dropdownfollowed bydropdown.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

A nurse is caring for a client who had a stroke and is immobile. Which of the following actions should the nurse take to maintain the client's skin integrity?

Correct Answer is B

Explanation

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