While changing a client's postoperative dressing, the nurse observes purulent drainage at the site.
Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

The correct answer is choice a. Ask the wife to stop and assess the client’s swallowing reflex.

Choice A rationale:

Assessing the client’s swallowing reflex is crucial because facial paralysis and inability to move one side can indicate a risk of aspiration. Ensuring the client can safely swallow before giving any fluids is a priority to prevent complications like aspiration pneumonia.

Choice B rationale:

Giving the wife a straw might seem helpful, but it does not address the underlying risk of aspiration. Without assessing the swallowing reflex, using a straw could still lead to aspiration.

Choice C rationale:

Assisting the wife in giving small sips of water without assessing the swallowing reflex first is unsafe. The client might not be able to swallow properly, increasing the risk of aspiration.

Choice D rationale:

Obtaining thickening powder is a good step for clients with swallowing difficulties, but it should be done after assessing the swallowing reflex. The priority is to first determine if the client can swallow safely.

Choice A rationale:

Use a peak flow meter to assess the respiratory status. Assessing the client's respiratory status using a peak flow meter is the most appropriate next action after administering albuterol, a bronchodilator. It helps determine the client's lung function and response to the medication. This information guides further interventions and treatment decisions.

Choice B rationale:

Administer a stat dose of corticosteroids. Administering corticosteroids may be indicated in some cases of respiratory distress or exacerbation of asthma. However, it should not be the immediate next step after albuterol administration. Assessing the client's response to albuterol through lung function testing (peak flow) is essential before deciding on additional medications.

Choice C rationale:

Document the normal finding in the client's health record. Documenting normal findings is important for maintaining accurate medical records, but in this case, it is premature. The nurse should first assess the client's response to albuterol and ensure that the respiratory status is indeed normal before documenting the findings.

Choice D rationale:

Repeat a dose of the client's rescue drug. Administering another dose of the rescue drug (albuterol) without assessing the client's response and lung function would not be the most appropriate action. It is essential to determine whether the initial dose was effective before considering additional doses or alternative treatments.