A client returns to the unit after having a bronchoscopy. The client states "my throat is so dry. Can I have a glass of water?". How will the nurse respond?
"I will give you some ice chips instead of a drink of water".
"I have to assess your gag reflex before giving you any food or water".
"I will call the primary health care provider and request an order for food and water".
"Let's try having a small sip of water to see if you can swallow".
The Correct Answer is B
A. Offering ice chips, might seem like a safe alternative, but it still poses a risk if the gag reflex is not intact.
B. Assessing the gag reflex is crucial before offering food or fluids to ensure the client can protect their airway and swallow safely. This response prioritizes safety and is appropriate to ensure the client does not aspirate.
C. Calling the healthcare provider to request orders for food and water may be necessary if there are specific protocols or if the client's condition requires further assessment or interventions before oral intake can be resumed. However, this response does not address the immediate need for comfort and hydration.
D. This response involves assessing the client's ability to swallow directly. While it addresses the client's request for water, it may not be the safest initial approach without first assessing the client's readiness and ability to swallow safely.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Canola oil is a healthier option compared to oils high in saturated fats, such as butter or lard. It does not significantly contribute to dietary cholesterol intake. Therefore, this statement does not indicate a need for follow-up teaching on a low-cholesterol diet.
B. Eggs are high in dietary cholesterol, and consuming two eggs daily can significantly increase cholesterol intake. For someone with elevated cholesterol levels or a history of atherosclerosis, this dietary habit may contribute to further elevation of cholesterol levels and potentially worsen cardiovascular health. Hence, this statement indicates the need for follow-up teaching on reducing dietary cholesterol intake.
C. Lemon juice is a low-calorie and low-cholesterol flavoring option. It does not significantly impact cholesterol intake. Therefore, this statement does not indicate a need for follow-up teaching on a low- cholesterol diet.
D. Omega-3 fatty acids are beneficial for heart health and do not contribute to dietary cholesterol intake. In fact, they may help reduce triglyceride levels and inflammation. Therefore, this statement does not indicate a need for follow-up teaching on a low-cholesterol diet.
Correct Answer is C
Explanation
A. Potassium levels are important for assessing electrolyte balance and are not directly indicative of protein intake or synthesis.
B. Calcium levels are important for bone health, nerve function, and muscle contraction. They are not directly indicative of protein intake or synthesis.
C. Albumin is a plasma protein that reflects the body's nutritional status and liver function. It has a relatively long half-life (approximately 20 days), making it a useful marker for assessing protein intake and synthesis over time. Low albumin levels can indicate malnutrition, liver disease, or other conditions affecting protein metabolism.
D. Sodium levels are important for fluid balance and nerve function. They are not directly indicative of protein intake or synthesis.
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