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 C
Explanation
A. A nonrebreather mask should not have a reservoir bag attached:
A nonrebreather mask must have a reservoir bag, which stores oxygen to deliver high concentrations.
B. A nonrebreather delivers the most precise oxygen concentration with humidity added:
The Venturi mask delivers the most precise oxygen concentration. Nonrebreathers do not add humidity and are not as precise.
C. A nonrebreather mask delivers the highest oxygen concentration possible outside of intubation:
A nonrebreather can deliver up to 95–100% FiO₂, the highest concentration available without intubation.
D. A nonrebreather mask does not impact eating or drinking:
The design of the mask covers the mouth and nose, making eating and drinking impractical while in use.
Correct Answer is C
Explanation
A. Dementia:
Dementia is a chronic, progressive cognitive decline, not an acute condition. It does not cause sudden, temporary disorientation post-surgery.
B. Alzheimer's disease:
Alzheimer's is a form of dementia and also a chronic, irreversible condition, not associated with acute postoperative confusion.
C. Postoperative delirium:
This is an acute, fluctuating mental status change that occurs shortly after surgery, especially in older adults. It's typically reversible and may include disorientation, agitation, or confusion.
D. Postoperative cognitive dysfunction (POCD):
POCD is usually more subtle and long-lasting, affecting memory and concentration weeks to months post-op, not an immediate disorientation after surgery.
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