A client who had a bronchoscopy 2 hours ago asks for a drink of water. What action would the nurse take initially to assure client safety?
Assess the client’s gag reflex before giving any food or water.
Provide the client with ice chips instead of a drink of water.
Contact the primary healthcare provider and get the appropriate orders.
Let the client have a small sip to evaluate the ability to swallow.
The Correct Answer is A
Choice A Reason:
Assessing the client’s gag reflex before giving any food or water is crucial after a bronchoscopy. The procedure involves the use of local anesthesia to numb the throat, which can impair the gag reflex and increase the risk of aspiration. Ensuring that the gag reflex has returned before allowing the client to eat or drink helps prevent choking and aspiration, which are serious complications.
Choice B Reason:
Providing the client with ice chips instead of a drink of water is not the best initial action. While ice chips may seem like a safer option, they still pose a risk of aspiration if the gag reflex has not fully returned. The priority is to first assess the gag reflex to ensure the client can safely swallow.
Choice C Reason:
Contacting the primary healthcare provider and getting the appropriate orders is not necessary as the first action. The nurse can independently assess the gag reflex, which is a standard nursing practice after procedures involving throat anesthesia. If there are concerns after the assessment, then contacting the healthcare provider would be appropriate.
Choice D Reason:
Letting the client have a small sip to evaluate the ability to swallow is not safe without first assessing the gag reflex. This approach could lead to aspiration if the gag reflex has not returned. The initial step should always be to assess the gag reflex to ensure the client can safely swallow liquids.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: An increase in temperature is not a primary indicator of hypovolemic shock. While fever can occur due to infection or inflammation, it is not directly related to hypovolemic shock, which is primarily characterized by a significant loss of blood or fluids leading to decreased perfusion and oxygenation of tissues.
Choice B reason: A decrease in urinary output is a critical sign of hypovolemic shock. When the body loses a significant amount of blood or fluids, the kidneys receive less blood flow, leading to reduced urine production. This is a compensatory mechanism to conserve fluids and maintain blood pressure. Normal urine output is typically around 30 to 50 mL per hour, so a drop below this range is concerning.
Choice C reason: An increase in heart rate is a common response to hypovolemic shock as the body attempts to maintain cardiac output and blood pressure despite the loss of blood volume. Tachycardia (increased heart rate) is one of the early signs of shock, indicating that the heart is working harder to pump blood to vital organs.
Choice D reason: A decrease in respiratory rate is not typical of hypovolemic shock. In fact, hypovolemic shock often leads to an increased respiratory rate (tachypnea) as the body tries to compensate for decreased oxygen delivery to tissues. A decrease in respiratory rate could indicate other issues but is not a hallmark of hypovolemic shock.
Correct Answer is ["A"]
Explanation
Choice A Reason:
Suction equipment at the bedside.
Having suction equipment at the bedside is crucial for a client with status epilepticus. During a seizure, there is a risk of aspiration due to excessive salivation or vomiting. Suction equipment allows the nurse to quickly clear the airway, preventing aspiration and ensuring the client can breathe properly. This precaution is essential to maintain the client’s airway and prevent complications such as aspiration pneumonia.
Choice B Reason:
Continuous sedation.
Continuous sedation is not typically a standard precaution for all clients with status epilepticus. While sedation may be necessary in some cases to control seizures, it is not a universal precaution. The primary goal is to stop the seizure activity and stabilize the client. Continuous sedation may be used in specific situations under close medical supervision, but it is not a general precaution that nurses implement for all clients with status epilepticus.
Choice C Reason:
Side rails padded.
Padding the side rails of the bed is an important precaution to prevent injury during a seizure. Clients experiencing seizures may have uncontrolled movements, which can lead to injury if they hit the hard surfaces of the bed. Padded side rails help to cushion these impacts, reducing the risk of bruises, cuts, or fractures. This precaution is essential for ensuring the client’s safety during seizure activity.
Choice D Reason:
Bed in low position.
Keeping the bed in a low position is another important safety measure. If a client with status epilepticus were to fall out of bed during a seizure, the lower height reduces the risk of serious injury. This precaution helps to minimize the impact of any potential falls, ensuring the client’s safety. It is a simple yet effective measure to prevent harm during seizure episodes.
Choice E Reason:
Intravenous (IV) access.
Establishing intravenous (IV) access is critical for a client with status epilepticus. IV access allows for the rapid administration of medications needed to control seizures and manage the client’s condition. In an emergency, quick access to the bloodstream is essential for delivering life-saving treatments. This precaution ensures that the medical team can promptly and effectively intervene to stop the seizure activity.
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