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".

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Metolazone is a thiazide-like diuretic that works primarily in the distal convoluted tubule of the nephron. It can lead to hyponatremia due to its mechanism of increasing sodium and water excretion. However, it is not typically associated with hyperkalemia.
B. Furosemide is a loop diuretic that acts on the ascending loop of Henle. It primarily causes loss of sodium, potassium, and chloride ions. While it can lead to hypokalemia (low potassium levels) due to increased potassium excretion, it does not typically cause hyperkalemia or hyponatremia.
C. Hydrochlorothiazide is a thiazide diuretic that acts on the distal convoluted tubule. It can cause hyponatremia due to increased sodium and water excretion. It may also lead to hypokalemia but is not typically associated with hyperkalemia.
D. Spironolactone is a potassium-sparing diuretic that works by antagonizing aldosterone receptors in the distal nephron, leading to retention of potassium and excretion of sodium. It can cause hyperkalemia due to its potassium-sparing effects. Additionally, it may also lead to hyponatremia, although less commonly than thiazide diuretics.

A. Encourage increased fluid take. B. Promote bed rest for 5-7 days. C. Place a pillow under the affected limb. D. Apply cool compresses to the affected limb every 6 hr.

Correct Answer is D

Explanation

A. Encouraging adequate fluid intake is important postoperatively to maintain hydration and support normal physiological functions. However, the amount of fluid intake should be within the client's tolerance and as prescribed by the healthcare provider. It helps prevent complications such as dehydration and promotes circulation, which is beneficial for wound healing.

B. While some rest and limited mobility are initially recommended after knee replacement surgery to allow for healing and to prevent complications, prolonged bed rest for 5-7 days is not typically necessary or recommended. Early mobilization and gradual increase in activity are encouraged to prevent complications such as deep vein thrombosis and to promote recovery.
C. Placing a pillow directly under the knee is not recommended as it can lead to decreased range of motion and potential contractures.
D. Cold therapy, such as applying cool compresses, is often used to reduce swelling and pain in the initial postoperative period. It can help manage pain and discomfort and promote comfort for the client.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing instruction to a new nurse about caring for clients who are receiving diuretic therapy to treat having actions should the nurse explain that which of the following medications puts clients at risk for both hyperkalemia and hyponatremia?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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