A nurse is caring for a client who is postoperative day 1, has a peripheral IV, and is requesting ice chips. Which of the following actions should the nurse take?
Check the client for bladder distention
Lower the head of the client's bed.
Remove the client's peripheral IV
Check the client's gag reflex.
The Correct Answer is D
A. Check the client for bladder distention:
This is unrelated to the request for oral intake. Bladder checks are more relevant to urinary retention, not swallowing safety.
B. Lower the head of the client's bed:
This increases risk of aspiration. The head of the bed should be elevated when consuming anything orally.
C. Remove the client's peripheral IV:
This is not appropriate. The IV may still be needed for medications, fluids, or emergencies.
D. Check the client's gag reflex:
This assesses swallowing safety to prevent aspiration, especially important post-anesthesia before giving oral intake.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Diarrhea:
Vomiting usually leads to fluid loss through emesis, not diarrhea. Diarrhea is a separate GI issue.
B. Dehydration:
Vomiting causes a loss of fluids and electrolytes, increasing the risk for dehydration and imbalances like hypokalemia.
C. Peripheral edema:
Edema indicates fluid retention, not loss. Vomiting causes fluid depletion, not accumulation.
D. Urinary frequency:
Vomiting leads to fluid loss, so urinary output is typically decreased, not increased.
Correct Answer is C
Explanation
A. Biofeedback:
Biofeedback involves using electronic monitoring to gain control over body functions (e.g., heart rate, muscle tension), not simply listening to music.
B. Guided Imagery:
Guided imagery involves mentally visualizing peaceful scenes or images, usually with a narrator guiding the process-not passive listening to music alone.
C. Distraction:
Music listening serves as a distraction, a nonpharmacologic method to divert attention away from pain.
D. Meditation:
Meditation typically involves focused breathing or mindfulness, not simply listening to music without intentional meditative practice.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.