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: A trochanter roll is used to prevent external rotation of the hips, not to prevent plantar flexion contractures.
B: A sheepskin heel pad provides cushioning and helps prevent pressure ulcers on the heels but does not prevent plantar flexion contractures.
C: A footboard is used to prevent plantar flexion contractures by keeping the feet in a neutral position. This helps maintain proper alignment and prevents the muscles and tendons from shortening.
D: An abduction pillow is used to maintain hip abduction, typically after hip surgery, and does not prevent plantar flexion contractures.
Correct Answer is A
Explanation
A: Posting a “No Smoking” sign in the home is crucial for safety when using home oxygen. Oxygen can accelerate combustion, making even a small spark potentially dangerous. This sign serves as a constant reminder to avoid smoking and open flames near the oxygen source.
B: Attaching oxygen containers to a fixed object is important to prevent them from falling over and potentially causing damage or leaks. However, this is not the most critical instruction compared to ensuring no smoking around oxygen.
C: Storing spare oxygen tanks in a closet is not recommended. Oxygen tanks should be stored in a well-ventilated area to prevent the buildup of oxygen, which could increase the risk of fire.
D: Notifying the fire department that oxygen is used in the home is a good safety measure. It ensures that emergency responders are aware of the presence of oxygen, which can affect their approach in case of a fire. However, it is not as immediate a safety measure as posting a “No Smoking” sign.
E: Ensuring oxygen tubing is no longer than 60 feet in length is important to maintain adequate oxygen flow and prevent tripping hazards. However, this is a secondary safety measure compared to preventing smoking around oxygen.
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