A nurse is caring for a client who is postoperative and has a peripheral IV, and is requesting ice chips. Which of the following actions should the nurse take?
Lower the head of the client’s bed.
Check the client’s gag reflex.
Remove the client’s peripheral IV.
Check the client for bladder distention.
The Correct Answer is B
A: Lowering the head of the client’s bed is not appropriate in this situation. It does not address the safety concern related to swallowing.
B: Checking the client’s gag reflex is the correct action. This ensures that the client can safely swallow ice chips without the risk of aspiration.
C: Removing the client’s peripheral IV is not related to the request for ice chips and is unnecessary unless there is a specific reason to do so.
D: Checking the client for bladder distention is not relevant to the request for ice chips and does not address the immediate concern of safe swallowing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.5"]
Explanation
Step 1: Determine the dosage required. 1 mg
Step 2: Determine the dosage per tablet. 2 mg per tablet
Step 3: Calculate the number of tablets needed. 1 mg ÷ 2 mg per tablet = 0.5 tablets
The nurse should administer 0.5 tablets per dose.
Correct Answer is D
Explanation
A: Having the client move in with a family member or close friend can provide emotional support and assistance with daily activities. However, it does not specifically address the safety needs related to hearing loss. While this option can be beneficial, it is not the most direct solution for ensuring the client’s safety in their home environment.
B: Encouraging the client to get a roommate can also provide companionship and assistance. However, like option A, it does not directly address the specific safety concerns associated with hearing loss. The presence of a roommate might help in emergencies, but it is not a guaranteed solution for all safety issues.
C: Increasing the sound on all alarms might seem like a logical step, but it is not effective for someone with full hearing loss. This approach does not ensure that the client will be alerted to emergencies, as they may not hear the alarms regardless of the volume.
D: Installing flashing lights for alarms is the most effective recommendation for a client with full hearing loss. Visual alarms can alert the client to emergencies such as fires or intruders, ensuring their safety. This solution directly addresses the client’s inability to hear auditory alarms and provides a reliable method for emergency alerts.
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