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 C
Explanation
A: Hyperkalemia refers to high potassium levels, which can occur in ESKD but does not directly cause shortness of breath, swelling, or crackles in the lungs.
B: Hyponatremia refers to low sodium levels, which can occur in ESKD but does not directly cause the symptoms described.
C: Hypervolemia, or fluid overload, is the most likely cause of the client’s symptoms. ESKD can lead to fluid retention, causing shortness of breath, swelling, crackles in the lungs, and elevated blood pressure.
D: Hypovolemia refers to low blood volume, which would not cause the symptoms of fluid overload described in the client.
Correct Answer is B
Explanation
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.
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