A nurse is assisting in the care of a client following a tonsillectomy who is alert and has an SpO2 of 93% on room air. Which of the following actions should the nurse take?
Obtain the client's peak expiratory flow volume.
Encourage the client to cough.
Place the client in a semi-Fowler's position.
Encourage the client to use a straw to sip cool liquids.
The Correct Answer is C
A. Obtain the client's peak expiratory flow volume: This is unnecessary in this context and not a routine assessment post-tonsillectomy.
B. Encourage the client to cough: Coughing can irritate the surgical site and increase the risk of bleeding.
C. Place the client in a semi-Fowler's position. Semi-Fowler's position promotes optimal airway clearance and reduces the risk of aspiration or airway obstruction.
D. Encourage the client to use a straw to sip cool liquids: Straws are contraindicated because the suction action can disrupt the surgical site and cause bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Testicular: Testicular cancer is the most common cancer in males aged 15–35, and regular self-examinations are recommended.
B. Skin: Routine skin examinations may be important but are less specific for this age group.
C. Prostate: Prostate cancer screenings typically start at age 50 or earlier for high-risk individuals.
D. Colorectal: Colorectal cancer screenings are recommended starting at age 45 unless there is a family history or risk factors.
Correct Answer is D
Explanation
A. "You will need to fast for 2 hours before the procedure." Bone marrow aspiration typically does not require fasting. If the procedure involves sedation, the client may be instructed to fast for a certain period, but fasting is not a standard requirement for bone marrow aspiration.
B. "You will have the bone marrow taken from your femur." While the femur (thigh bone) can be a site for bone marrow aspiration, the most common site is the posterior iliac crest (the back of the pelvis). The nurse should clarify the exact site with the healthcare provider.
C. "You will not receive a local anesthetic agent for this procedure." Bone marrow aspiration is typically performed under local anesthesia to minimize discomfort at the site. The client will feel pressure during the procedure but should not experience pain due to the anesthesia.
D. "I will hold pressure on the site after the procedure." After a bone marrow aspiration, the nurse will apply pressure to the site to control any bleeding and help prevent hematoma formation. This is an important part of post-procedure care.
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