A nurse in a PACU is admitting a client who is postoperative following a tonsillectomy.
Which of the following actions should the nurse plan to take to prevent aspiration?
Suction the nasopharynx as needed.
Withhold fluids until the client demonstrates a gag reflex.
Perform chest physiotherapy.
Place a bedside humidifier at the head of the client's bed.
The Correct Answer is B
A. Suctioning the nasopharynx as needed can help maintain airway patency but does not directly prevent aspiration during the recovery period.
B. Withholding fluids until the client demonstrates a gag reflex is a standard precaution to prevent aspiration, particularly in the immediate postoperative period.
C. Chest physiotherapy is not specifically indicated for preventing aspiration in the post- tonsillectomy period.
D. Placing a bedside humidifier at the head of the client's bed is not a specific intervention for preventing aspiration after tonsillectomy. Monitoring the client's ability to swallow and the return of the gag reflex is more relevant.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Projectile vomiting in an infant could be indicative of a serious condition, and advising on burping may not be sufficient. A prompt assessment by a healthcare provider is needed.
B. Projectile vomiting can be a concerning sign and may be associated with conditions such as pyloric stenosis. Bringing the baby to the clinic for evaluation is the appropriate action.
C. Switching formula may not address the underlying cause of projectile vomiting, and it is crucial to determine the cause through a thorough examination.
D. While oral rehydration solution may be used for dehydration, the priority is to assess the infant in person to determine the cause of the vomiting.
Correct Answer is D
Explanation
A. Poor fluid intake may be a concern postoperatively, but it is not a specific manifestation of hemorrhage.
B. Increased pain is expected after a tonsillectomy, especially in the immediate postoperative period, but it is not a specific sign of hemorrhage.
C. Drooling is not related to haemorrhage post tonsillectomy.
D. This symptom may indicate that the child is swallowing blood that is oozing from the surgical site. It is important for healthcare providers to recognize this sign promptly as post-tonsillectomy hemorrhage can be a serious complication requiring immediate attention.
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