A nurse is caring for a client who is postoperative following ambulatory surgery requiring general anesthesia. Which of the following actions should the nurse take?
Offer the client oral fluids when awake
Discontinue IV fluid infusion on arrival to the PACU
Check the client's vital signs once every hour until awake
Maintain the client in a supine position.
The Correct Answer is A
A. Offering oral fluids once the client is awake and has a gag reflex is appropriate to prevent dehydration and ensure the client can safely swallow.
B. Discontinuing IV fluids immediately upon arrival to the PACU is inappropriate, as the client may still need fluid support until they are fully stable and able to tolerate oral intake.
C. Checking vital signs only once every hour is too infrequent in the immediate postoperative phase. Vital signs should be monitored every 15 minutes initially.
D. Maintaining a supine position is not ideal after general anesthesia due to the risk of airway obstruction. A lateral or semi-Fowler's position is safer to promote airway patency.
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Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"A"}}
Explanation
Administer an iron supplement: Client has iron-deficiency anemia evidenced by low hemoglobin, hematocrit, and ferritin. Iron supplementation is first-line therapy, especially for clients with vegan diets who lack dietary iron.
Restrict fluid intake: This is contraindicated for this client. There is no evidence of fluid overload, CHF, or renal failure requiring restriction. Fluid restriction could worsen fatigue, hypotension, and perfusion.
Place the client on a low sodium diet: This is not critical for current anemia management. May be beneficial for long-term hypertension management, but not directly related to anemia treatment.
Refer for a nutritional consult: Client follows a vegan diet and is at risk for iron and B12 deficiency. A dietitian can provide guidance on iron-rich plant foods, B12 supplementation, and balanced nutrition.
Correct Answer is C
Explanation
A. Tubing should be kept straight and free of kinks or coils to ensure proper drainage, not coiled or hung.
B. The drainage system should be kept below the client’s chest level to prevent backflow of fluid into the pleural space.
C. Assessing vital signs every 30 minutes for the first 3 hours is appropriate to monitor for complications after chest tube insertion.
D. Bubbling in the water seal chamber is expected with coughing or exhalation; continuous bubbling may indicate an air leak, so assessing for bubbling is important but not specifically with exhalation or cough only.
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