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 C
Explanation
A. "Insert an indwelling urinary catheter and record the client's output.": This is not relevant to a thoracentesis, which focuses on the pleural cavity, not urinary output.
B. "Set up the equipment using clean technique.": Sterile technique is required to prevent infection during the invasive procedure.
C. "Prepare the client for a chest x-ray following the procedure.": A chest x-ray is performed post-thoracentesis to ensure the lung has re-expanded and to rule out complications like pneumothorax.
D. "Instruct the client to remain flat in bed for 4 to 6 hr after the procedure.": The client does not need to remain flat; instead, they are typically observed for respiratory complications in a sitting or semi-Fowler’s position.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Correct answer: The nurse should first plan to determine if the nasogastric tube is in the correct position, followed by monitoring the client's electrolyte levels.
Determine if the nasogastric tube is in the correct position: It is crucial to ensure the nasogastric tube is correctly positioned to allow for proper drainage and to prevent complications such as aspiration.
Monitor the client's electrolyte levels: Given the client’s abnormal laboratory results (low sodium and potassium levels), it's important to closely monitor electrolytes to prevent further imbalances and complications.
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