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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Correct Answer is C

Explanation

A. "Plan to hire a home care aide to perform all of your ADLs.": Encouraging independence is vital for rehabilitation. Assistance should be provided only as needed.
B. "You will not become fatigued when you use assistive devices.": Using assistive devices can still be tiring; clients should be informed to take frequent breaks.
C. "Install grab bars in your shower to assist with your balance." Grab bars are essential for safety, as clients who have a CVA may have weakness or poor balance, increasing the risk of falls.
D. "Place a towel in the shower to prevent slipping.": Towels in the shower are not safe and can increase the risk of slipping. A non slip mat is a better alternative.

A. Client is alert and oriented to person, place, and time B. Bilateral breath sounds clear and present throughout C. Bilateral pedal pulses 3+ D. Feet warm with intact movement and sensation E. Client reports pain as a 4 on a scale of 0 to 10

Correct Answer is ["A","B","C","D","E"]

Explanation

These findings indicate improvements in overall status:

Alert and oriented: No neurological impairment.
Clear breath sounds: No signs of respiratory compromise.
Pedal pulses and warm feet: Circulation is restored.
Reduced pain: Indicates effective pain management.

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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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Correct Answer is C

Explanation

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Explanation

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