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 ["4.0"]
Explanation
Step 1: Determine the dosage required. 320 mg
Step 2: Determine the concentration of the suspension. 400 mg per 5 mL
Step 3: Calculate the volume needed. 320 mg ÷ 400 mg per 5 mL = 320 ÷ 400 × 5 = 0.8 × 5 = 4 mL
The nurse should administer 4.0 mL per dose.
Correct Answer is A
Explanation
A: Providing the client with a diet high in protein is essential for maintaining skin integrity. Protein is crucial for tissue repair and regeneration, which helps prevent skin breakdown and promotes healing of existing wounds.
B: Repositioning the client every 3 hours is less effective than the recommended every 2 hours. Frequent repositioning helps to relieve pressure on vulnerable areas and prevent pressure injuries.
C: Massaging bony prominences is not recommended as it can cause further damage to already fragile skin and underlying tissues. Gentle handling and avoiding pressure on these areas are more appropriate.
D: Applying cornstarch to keep the skin dry is not advisable as it can lead to skin irritation and breakdown. Instead, using moisture-wicking products and maintaining proper skin hygiene are better practices.
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