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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. "Perform breast self-examinations during the middle of your cycle.": The best time for premenopausal clients to perform a breast self-exam is 5-7 days after the menstrual period ends, when hormonal fluctuations are minimal, and the breasts are less tender.
B. "Perform breast self-examinations while lying on your side.": The recommended position for self-examination is lying flat with the arm on the side being examined raised above the head, as this spreads the breast tissue more evenly.
C. "Use small, circular motions, working vertically up and down across the breast.": The vertical strip method, using small circular motions, is the recommended technique for thorough breast self-examination. It ensures that all breast tissue is palpated, including the axillary area.
D. "Use the palm of your hand to detect the presence of any large masses under the skin.": The pads of the fingers, not the palm, are used to palpate the breast for lumps or abnormalities.

A. Trendelenburg with legs extended B. Supine with knees flexed C. Semi-Fowler's with legs extended D. Left-lateral with knees flexed

Correct Answer is B

Explanation

A. "Trendelenburg with legs extended.": Trendelenburg increases pressure on the abdomen, worsening evisceration.
B. "Supine with knees flexed.": This position reduces abdominal tension, minimizing further protrusion of the contents and providing comfort until surgical intervention.
C. "Semi-Fowler's with legs extended.": This position does not adequately reduce abdominal tension.
D. "Left-lateral with knees flexed.": Lateral positions are not suitable because they do not address abdominal tension or allow easy surgical access.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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