The practical nurse (PN) is assigned to care for a client who had an endoscopic procedure in which a local anesthetic was sprayed on the throat. Which priority action should the PN include in this client's plan of care?
Observe for belching.
Inquire about a sore throat.
Assess the gag reflex
Instruct the client to speak.
The Correct Answer is C
A. Observe for belching: While belching is a normal gastrointestinal function, it is not a priority safety concern after a local anesthetic is applied to the throat. It does not directly indicate airway protection or swallowing ability.
B. Inquire about a sore throat: Sore throat is a common minor side effect after endoscopy, but it does not pose an immediate risk to the client. Assessing discomfort is secondary to ensuring safety.
C. Assess the gag reflex: The priority is to assess the gag reflex before allowing the client to eat or drink. Local anesthetic can temporarily suppress the reflex, increasing the risk of aspiration if swallowing occurs prematurely, making this a critical safety intervention.
D. Instruct the client to speak: Asking the client to speak can help assess vocal cord function but does not provide reliable information about airway protection or swallowing safety, which are more urgent concerns post-procedure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Increased diaphoresis during the day and night: Profuse sweating is common in the early postpartum period as the body eliminates excess fluid accumulated during pregnancy. It is a normal physiological response and does not usually require reporting unless accompanied by other abnormal symptoms.
B. Sudden or persistent temperature above 100.5° F (38.0° C): A sustained elevated temperature may indicate infection such as endometritis, mastitis, or urinary tract infection. Prompt reporting is essential for timely evaluation and intervention to prevent systemic complications.
C. Breast engorgement on the fourth postpartum day: Engorgement typically occurs when milk production increases, usually around the third or fourth day postpartum. It is a normal finding that can be managed with frequent breastfeeding, ice packs, or mild analgesics.
D. Lochia color that changes to light pink or white: The transition from lochia rubra to serosa and eventually alba (light pink to white) signifies normal uterine healing. This gradual color change is expected and not a sign of pathology.
Correct Answer is C
Explanation
A. "Be sure to keep the client supplied with plenty of fluids.": While hydration after a lumbar puncture helps reduce the risk of post-procedure headache, encouraging or monitoring fluid intake is part of routine nursing care and does not require delegation to the UAP as a primary instruction.
B. "It is important to monitor the appearance of the puncture site.": Assessment of the puncture site for drainage, redness, or swelling requires nursing judgment and should be performed by the PN or RN, not delegated to the UAP.
C. "Let me know if there is a significant change in the vital signs.": The UAP can accurately measure and report vital signs. Sudden changes, such as hypotension or tachycardia, may indicate complications like cerebrospinal fluid leakage or bleeding, requiring prompt nurse evaluation.
D. "Report any change in the client's distal circulation checks.": Circulatory checks are not typically indicated following a lumbar puncture because the procedure does not affect limb perfusion; therefore, this instruction is not relevant to the client’s condition.
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