NCLEX Challenge 3 Spring 2020

A nurse is caring for a client who has active pulmonary tuberculosis (TB) and is to be started on intravenous rifampin therapy. The nurse should instruct the client that this medication can cause which of the following adverse effects? Constipation Black colored stools Staining of teeth Body secretions turning a red-orange color

Body secretions turning a red-orange color Rifampin is used in combination with other medicines to treat TB. Rifampin will cause the urine, stool, saliva, sputum, sweat, and tears to turn reddish-orange to reddish-brown.

A nurse is caring for a client who has central venous catheter and develops acute shortness of breath. Which of the following actions should the nurse take first? Clamp the catheter. Position the client in left lateral Trendelenburg. Initiate oxygen therapy. Auscultate breath sounds.

Clamp the catheter. The greatest risk to this client is injury from further air entering the central venous catheter; therefore, the first action the nurse should take is to clamp the catheter.

A charge nurse notes that a staff nurse delegates an unfair share of tasks to the assistive personnel (AP) and the nurses on next shift report the staff nurse frequently leaves tasks uncompleted. Which of the following statements should the charge nurse make to resolve this conflict? "I need to talk to you about unit expectations regarding delegating and completing tasks." "Several staff members have commented that you don't do your fair share of the work." "If you don't do your share of the work, I will have to inform the nurse manager." "You have been very inconsiderate of others by not completing your share of the work."

"I need to talk to you about unit expectations regarding delegating and completing tasks." This statement opens the conversation in a nonthreatening way. The focus is on the issue of the equity of the assignment rather than on any personal characteristic of the individual.

A nurse in the emergency department is assessing an older adult client who has community-acquired pneumonia. Which of the following findings should the nurse expect? Unequal pupils Hypertension Tympany upon chest percussion Confusion

Confusion Confusion due to hypoxemia is an expected finding for an older-adult who has pneumonia.

The nurse is admitting a client who is having an exacerbation of his asthma. When reviewing the provider's orders, the nurse recognizes that classification is needed for which of the following medications? Propranolol Theophylline Montelukast Prednisone

Propranolol Medications that block beta-2 receptors, such as propanolol, are contraindicated in clients with asthma.

A nurse is attempting to flush the IV saline lock for a client. The client reports pain above the catheter site. Which of the following actions should the nurse take? Inject the solution more slowly while flushing the IV saline lock. Apply a warm compress to the IV site. Apply firm pressure to the plunger of the syringe during the IV flush to improve patency. Remove the IV saline lock.

Remove the IV saline lock. The nurse should remove and move the IV catheter to another location because evidence indicates that the lock is not functioning properly.

A nurse is preparing to obtain a blood specimen from a client by venipuncture. The client is receiving IV fluids through an IV catheter inserted in the basilica vein of the right forearm. Which of following sites should the nurse plan to use to obtain the blood specimen? Left upper arm Right forearm Foot Left forearm

Left forearm This site is in the antecubital fossa, which allows for easy access and does not interfere with the client's IV catheter and infusion. The nurse should use this site to obtain a blood specimen.

A nurse is caring for a client who has a central venous catheter and suddenly develops chest pain, dyspnea, dizziness, and tachycardia. the nurse suspects air embolism and clamps the catheter immediately. What other action should the nurse take at this time? Prepare for chest tube insertion. Place the client on his left side in Trendelenburg position. Remove the catheter. Replace the infusion system.

Place the client on his left side in Trendelenburg position. This position helps trap the air in the apex of the right atrium rather than allowing it to enter the right ventricle and move to the pulmonary arterial system.

A client has a right subclavian central venous catheter. When reconnecting a new administration set, which of the following instructions should the nurse give the client? "Exhale slowly." "Turn head to the right." "Sit in semi-Fowler's position." "Bear down while holding breath."

"Bear down while holding breath." The client should perform a Valsalva maneuver by holding a breath and bearing down while the nurse disconnects the old set and reconnects the new set. This action prevents air from entering the lumen, the heart, and pulmonary circulation.

A nurse is caring for a client who has advanced lung cancer. The client's provider has recommended hospice services for the client. Which of the following statements by the client indicates a correct understanding of hospice care? "I will have to be admitted to a long-term care facility in order to receive hospice care." "I should expect the hospice team to help me manage my dyspnea." "Hospice care services are available to patients who are terminally ill regardless of their life expectancy." "My oncologist will continue to look for a cure for my cancer while I am receiving hospice care."

"I should expect the hospice team to help me manage my dyspnea." Dyspnea is a manifestation of terminal lung cancer. The primary purpose of hospice care is to provide relief of symptoms related to a terminal illness.

A nurse is teaching the mother of a 5-year-old child who has cystic fibrosis about pancreatic enzymes. The nurse should understand that further teaching is necessary when the mother states which of the following? "I will give my son the enzymes between meals." "The enzymes probably won't cause many adverse effects." "The enzymes help him digest fat." "I will put the enzyme crystals in his applesauce."

"I will give my son the enzymes between meals." The parent should give the child pancreatic enzymes with every meal and snack.

A nurse is teaching a client who is about to undergo the insertion of a non tunneled central venous access device. Which of the following statements should the nurse identify as an indication that the client understands the instructions? "I will have to stay in bed for several hours after the procedure." "I will turn my head in the opposite direction during insertion." "I will need to hold my breath when they first put the needle in." "I will call the clinic if I have persistent hiccups."

"I will turn my head in the opposite direction during insertion." The client should turn his head away from the insertion site to allow optimal accuracy in placing the catheter.

The nurse is assessing a client who is to undergo a left lobectomy to treat lung cancer. The client tells the nurse that she is scared and wishes she had never smoked. Which of the following responses should the nurse make? "It's okay to feel scared. Let's talk about what you are afraid of." "Don't worry. The important thing is you have now quit smoking." "I understand your fears. I was a smoker also." "Your doctor is a great surgeon. You will be fine."

"It's okay to feel scared. Let's talk about what you are afraid of." It is the nurse's responsibility to acknowledge the client's statement, to encourage verbalization, and to explore the client's feelings.

A nurse is preparing to administer total parenteral nutrition (TPN) 1800 mL to infuse over 24 hr. The nurse should set the IV pump to deliver how many mL/hr?

75 mL/hr STEP 1: What is the unit of measurement the nurse should calculate? mL/hr STEP 2: What is the volume the nurse should infuse? 1800 mL STEP 3: What is the total infusion time? 24 hr STEP 4: Should the nurse convert the units of measurement? NoSTEP 5: Set up an equation and solve for X. Volume (mL)/Time (hr) = X mL/hr 1800 mL/24 hr = X mL/hr X = 75 STEP 6: Round if necessary. STEP 7: Reassess to determine whether the amount to administer makes sense. If the prescription reads TPN 1800 mL to infuse over 24 hr, it makes sense to administer 75 mL/hr. The nurse should set the IV pump to deliver TPN IV at 75 mL/hr.

A nurse is caring for a client who has lung cancer and is scheduled for a lobectomy. The nurse should prepare the client to expect which of the following after the procedure? A sternal incision A chest tube Moderate pain Pulmonary function studies

A chest tube A lobectomy is major surgery that involves a large posterolateral or anterolateral incision into bone, muscle, and cartilage. Chest tubes are placed to drain air and fluid and remain in place for several days postoperatively.

A nurse is caring for a client who requires isolation for active pulmonary tuberculosis. Which of the following precautions should the nurse include when creating a sign to post outside of the client's room? (select all that apply)

A protective mask is correct. Clients who have active pulmonary tuberculosis require airborne precautions. Everyone entering the room requires respiratory protection, in the form of an appropriate filtration mask. A closed door is correct. Clients who have active pulmonary tuberculosis require airborne precautions. Everyone entering or leaving the room should close the door behind them. A gown is incorrect. Gowns are unnecessary for every individual entering the room; however, any staff who anticipate contact with body fluids should wear them. A puncture-proof sharps container is correct. Nurses must always dispose of needles and sharp instruments in puncture-proof sharps containers. Hand hygiene is correct. Hand hygiene is essential before and after all contact with clients.

A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which if the following room assignments should the nurse make for the client? A room with air exhaust directly to the outdoor environment A room with another nonsurgical client A room in the ICU A room that is within view of the nurses' station

A room with air exhaust directly to the outdoor environment A room with air exhaust directly to the outside environment eliminates contamination of other client-care areas. This type of ventilation system is referred to as an airborne infection isolation room.

A nurse is planning care for a child who has cystic fibrosis and a prescription to receive chest physiotherapy (CPT). Which of the following actions should the nurse plan to take? Percuss each lung segment for 15 min. Perform CPT immediately after the child eats. Administer albuterol prior to CPT. Perform vibration during the client's inspirations.

Administer albuterol prior to CPT. Albuterol is a bronchodilator that relaxes and dilates the airway to promote air exchange. The nurse should administer the medication prior to implementing CPT to improve airway clearance. Albuterol facilitates the removal of the secretions as the chest wall is being percussed.

A nurse in a urgent care center is caring for a client who is having an acute asthma exacerbation. which of the following actions is the nurse's highest priority? Initiating oxygen therapy Providing immediate rest for the client Positioning the client in high-Fowler's Administering a nebulized beta-adrenergic

Administering a nebulized beta-adrenergic The greatest risk to the client's safety is airway obstruction. Beta-adrenergic medications act as bronchodilators. They provide prompt relief of airflow obstruction by relaxing bronchiolar smooth muscle and are the initial priority intervention when a client has an acute asthma exacerbation.

A nurse is teaching a client who has been taking prednisone to treat asthma and has a new prescription to discontinue the medication. The nurse should explain to the client to reduce the dose gradually to prevent which of the following adverse effects? Hyperglycemia Adrenocortical insufficiency Severe dehydration Rebound pulmonary congestion

Adrenocortical insufficiency Prednisone, a corticosteroid, is similar to cortisol, the glucocorticoid hormone produced by the adrenal glands. It relieves inflammation and is used to treat certain forms of arthritis, severe allergies, autoimmune disorders, and asthma. Administration of glucocorticoids can suppress production of glucocorticoids, and an abrupt withdrawal of the drug can lead to a syndrome of adrenal insufficiency.

The nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect? Nausea Dysphagia Agitation Hypotension

Agitation The nurse should expect agitation due to neurological changes from poor oxygen exchange.

A home health nurse visits a client who has COPD and receives oxygen at 2L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse's priority? Increase the oxygen flow to 3 L/min. Assess the client's respiratory status. Call emergency services for the client. Have the client cough and expectorate secretions.

Assess the client's respiratory status. The first action the nurse should take using the nursing process is to collect data from the client. The nurse should immediately assess the client's respiratory status before determining the appropriate interventions.

The nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which of the following actions should the nurse take? Attach a humidifier bottle to the base of the flow meter. Remove the nasal cannula while the client eats. Secure the oxygen tubing to the bed sheet near the client's head. Apply petroleum jelly to the nares as needed to soothe mucous membranes.

Attach a humidifier bottle to the base of the flow meter. Oxygen therapy can dry the mucous membranes. The nurse should attach humidification for a client receiving oxygen greater than 4 L/min via nasal cannula.

A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure, which of the following nursing actions should the nurse complete first? Auscultate lung fields. Assess pulse and respirations. Assess characteristics of her sputum. Instruct to slowly exhale with pursed lips.

Auscultate lung fields. The first action the nurse should take when using the airway, breathing, circulation (ABC) approach to client care is to auscultate lung fields to provide knowledge of which lung areas are most affected and would be the focus of the procedure.

A nurse is assessing a client who has COPD. The nurse should expect the client's chest to be which of the following shapes? Pigeon Funnel Kyphotic Barrel

Barrel Clients who have COPD use accessory muscles to assist with respiratory effort. The use of those accessory muscles causes the chest wall to eventually increase in anterior-posterior diameter, making it appear barrel shaped.

A nurse is assessing an older adult client who is receiving IV therapy. The nurse should recognize that which of the following findings indicates fluid volume excess? (select all that apply) Bounding pulse Pitting edema Swelling at the IV site Urine-specific gravity greater than 1.030 Crackles upon auscultation

Bounding pulse - Fluid volume excess is due to excessive fluid intake or inadequate fluid excretion. Manifestations include increased blood pressure, pulse, and respirations. With fluid volume excess, the pulse is full and bounding. Pitting edema - Excess extracellular fluid can lead to pitting edema in dependent areas of the body. Crackles upon auscultation - Pulmonary edema can occur with fluid volume excess.

While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen, and painful and that the surrounding tissues are hard. Which of the following actions should the nurse take first? Discontinue the existing IV line. Initiate a new IV line in the other extremity. Apply a hot pack to the irritated site. Determine if the client needs to continue IV therapy.

Discontinue the existing IV line. The greatest risk to the client is injury from the IV infiltration damaging soft tissues surrounding the catheter. Therefore, the first action the nurse should take is to discontinue the existing IV line.

A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions? Encourage the client to ambulate frequently. Encourage coughing and deep breathing. Encourage the client to increase fluid intake. Encourage regular use of the incentive spirometer.

Encourage the client to increase fluid intake. Increasing fluid intake to1,500 to 2,500 mL/day promotes liquefaction and thinning of pulmonary secretions, which improves the client's ability to cough and remove the secretions.

A nurse is caring for a client who has COPD. The client tells the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions? Maintaining a semi-Fowler's position as often as possible Administering oxygen via nasal cannula at 2 L/min Helping the client select a low-salt diet Encouraging the client to drink 2 to 3 L of water daily

Encouraging the client to drink 2 to 3 L of water daily COPD is a term for two diseases of the respiratory system: chronic bronchitis and emphysema. Maintaining hydration through the consumption of adequate fluids will help liquefy thick secretions and facilitate their expectoration.

A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client? Respiratory alkalosis Increased anteroposterior diameter of the chest Oxygen saturation level 96% Petechiae on chest

Increased anteroposterior diameter of the chest The nurse should anticipate an increased anteroposterior diameter of the chest (barrel chest) because of chronic hyperinflation of the lungs.

A nurse is teaching a client who has asthma how to use a metered-dose inhaler (MDI). The nurse identifies the sequence of steps the client should follow. Inhale deeply and then exhale completely. Place her lips firmly around the mouthpiece. Breathe in deeply over 2 to 3 seconds while pushing down on the canister. Hold her breath for 10 seconds. Exhale slowly through pursed lips. Wait 60 seconds between each puff.

Inhale deeply and then exhale completely. Place her lips firmly around the mouthpiece. Breathe in deeply over 2 to 3 seconds while pushing down on the canister. Hold her breath for 10 seconds. Exhale slowly through pursed lips. Wait 60 seconds between each puff.

A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan? Restrict the client's fluid intake to less than 2 L/day. Provide the client with a low-protein diet. Have the client use the early-morning hours for exercise and activity. Instruct the client to use pursed-lip breathing.

Instruct the client to use pursed-lip breathing. Pursed-lip breathing lengthens the expiratory phase of respiration and also increases the pressure in the airway during exhalation. This action reduces airway resistance and decreases trapped air for clients who have COPD.

A nurse is collaborating on care for a client who has COPD. Which of the following tasks should the nurse recommend be referred to an occupational therapist for assistance? Instructing how to measure oxygen saturation Instructing how to use kitchen tools to prepare a meal Instruction how to plan a diet based on individual caloric needs Instructing how to perform pursed-lip breathing

Instructing how to use kitchen tools to prepare a meal As a member of the interdisciplinary team, the occupational therapist works with the client to develop fine motor skills and coordination, such as improving hand strength and hand movements. The occupational therapist focuses on self-management of ADLs, such as skills needed for eating, hygiene, and dressing. Occupational therapists also can teach clients to perform other independent living skills, such as cooking and shopping.

The nurse is caring for a client who is receiving total parenteral nutrition via a peripherally inserted central catheter (PICC). When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Which of the following actions should the nurse take first? Measure the circumference of both upper arms. Notify the provider who inserted the PICC line. Remove the PICC line. Apply a cold pack to the client's upper arm.

Measure the circumference of both upper arms. The first action the nurse should take using the nursing process is to assess the client. The nurse should measure the arm and compare the result with the circumference of the other arm. If the arm is swollen, the nurse should notify the provider who inserted the PICC line. Swelling could indicate formation of a clot above the site or even catheter rupture.

A nurse is caring for a client who has asthma and developed viral pharyngitis. Which of the following findings should the nurse expect? Petechiae on the chest and the abdomen WBC 16,000/mm3 Negative throat culture Severe hyperemia of pharyngeal mucosa

Negative throat culture A client who has viral pharyngitis will have a negative throat culture. A client who has bacterial pharyngitis usually has a throat culture positive for beta-hemolytic streptococcus.

A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis? Oral mucosa Conjunctivae Ear lobes Soles of the feet

Oral mucosa According to evidence-based practice, the nurse should first monitor the client's tongue and lips for manifestations of central cyanosis because cyanosis is most evident in areas with minimal pigmentation.

A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter, the client reports pain in the insertion area. Which of the following actions should the nurse take? Remove the catheter and insert another into a different site. Administer an analgesic PO. Request a prescription for placement of a central venous access device. Administer a local anesthetic.

Remove the catheter and insert another into a different site. It is possible that the catheter is up against a valve or near a nerve and is causing more pain than an IV catheter insertion should. The nurse should remove the source of the pain and establish peripheral IV access elsewhere.

A nurse is giving a presentation at a community center about chronic bronchitis. Which of the following information should the nurse include as effective for preventing this disorder? Maintenance of ideal weight Annual influenza immunization Smoking cessation Regular moderate exercise

Smoking cessation Smoking is a major cause of chronic bronchitis; therefore, smoking cessation is an effective preventive strategy.

A nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis. Which of the following tests should the nurse realize is the most reliable to confirm the diagnosis of active pulmonary TB? Chest x-ray Sputum culture for acid-fast bacillus Sputum smear Mantoux test

Sputum culture for acid-fast bacillus Although the Mantoux (skin test) and the chest x-ray may be useful screening tools for TB, the presence of acid-fast bacillus noted in the client's sputum, secretions, or tissues is the only method that can actually confirm the diagnosis.

The nurse is caring for a client who has a single lumen central venous catheter. Which of the following actions should the nurse take when assessing the catheter? Use a 10-mL syringe to flush the catheter. Flush the lumen with sterile water after each use. Use clean technique when accessing the catheter. Apply firm pressure to the syringe plunger when flushing the lumen.

Use a 10-mL syringe to flush the catheter. During the flushing procedure, the nurse should use a 10-mL barrel syringe, because the pressure that is exerted by smaller barrel syringes increases the risk for rupturing the catheter.

The nurses auscultating the breath sounds of a client who has asthma. when the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious breath sounds? Crackles Rhonchi Stridor Wheezes

Wheezes Wheezes are continuous, high-pitched squeaking sounds, first evident on expiration, but possibly evident on inspiration as the airway obstruction of asthma worsens. Wheezes are often audible without a stethoscope.

The nurse is working with a licensed practical nurse (LPN) to care for a client who is receiving a continuous IV infusion. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site? "The infusion rate has stopped but the tubing is not kinked." "The area surrounding the insertion site feels warm to the touch." "There is fluid leaking around the insertion site." "There is no blood return when the tubing is aspirated."

"The area surrounding the insertion site feels warm to the touch." The IV fluid is at room temperature, so the area around the injection site will feel cool, not warm, to the touch when the IV is infiltrated. A warm area around the injection site indicates infection or phlebitis.

An assistive personnel (AP) comes to work with a new set of artificial nails. The nurse takes the AP to a private location to discuss the issue. Which of the following statements by the nurse is appropriate? "There is a higher risk of infection for our clients associated with artificial nails." "You should know that artificial nails have a very unprofessional appearance." "I want you to review the facility's policy on personal attire before you begin the shift." "Why would you wear artificial nails to work when you know it's against the rules?"

"There is a higher risk of infection for our clients associated with artificial nails." Short, natural nails are less likely to harbor pathogens that can be harmful to clients. The CDC recommends health care workers avoid wearing artificial nails when caring for clients who are at risk for infection. Additionally, guidelines from the World Health Organization prohibit artificial nails for caregivers in every setting.

The nurse enters an older adult client's room to insert a saline lock. The client asks the nurse, "Why do I need that? I am drinking plenty of fluids." Which of the following responses should the nurse provide? "It is quicker to administer medications intravenously in the hospital." "Clients over the age of 65 must have a saline lock according to facility policy." "We administer all medications intravenously to clients in this unit." "Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours."

"Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours." Intermittent antibiotic medications are frequently administered parenterally. This allows the client to ambulate between medication administrations, enhances client safety and promotes comfort. The response addresses the client's concern.

The nurse is assessing a client who is receiving total parenteral nutrition (TPN) therapy via an infusion pump. Which of the following actions should the nurse take? Obtain the client's blood glucose every 12 hr. Change the IV tubing every 24 hr. Change the IV site dressing every 4 days. Weigh the client every other day.

Change the IV tubing every 24 hr. The nurse should change the client's IV tubing every 24 hr, or per facility protocol, to prevent bacteria from developing in the tubing.

A nurse is auscultating a client's lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take? Repeat auscultation after asking the client to breathe deeply and cough. Instruct the client to limit fluid intake to less than 2,000 mL/day. Prepare to administer antibiotics. Place the client on bed rest in semi-Fowler's position.

Repeat auscultation after asking the client to breathe deeply and cough. Although crackles often indicate fluid in the alveoli, they can also be the result of positioning or decreased ventilation. They sometimes clear after a deep breath or a cough.

A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mm Hg. Which of the following actions should the nurse take first? Stop the infusion of blood. Inform the provider. Obtain a urine specimen. Notify the laboratory.

Stop the infusion of blood. This client is experiencing an acute intravascular hemolytic transfusion reaction. The greatest risk to this client is injury from receiving additional blood; therefore, the first action the nurse should take is to stop the infusion of blood.

A nurse is teaching a client who has asthma about how to use an albuterol inhaler. Which of the following actions by the client indicates an understanding of the teaching? The client holds his breath for 10 seconds after inhaling the medication. The client takes a quick inhalation while releasing the medication from the inhaler. The client exhales as the medication is released from the inhaler. The client waits 10 min between inhalations.

The client holds his breath for 10 seconds after inhaling the medication The medication should be retained in the lungs for a minimum of 10 seconds so the maximum amount of the dosage can be delivered properly to the airways. To use the inhaler, the client exhales normally just prior to releasing the medication, inhales deeply as the medication is released, then holds the medication in the lungs for approximately 10 seconds prior to exhaling.

A nurse is providing discharge teaching to a client who has asthma and a new prescription for fluticasone/salmeterol. For which of the following adverse effects should the nurse instruct the client to report to the provider? Sedation Increased appetite White coating in the mouth Dry oral mucous membranes

White coating in the mouth Fluticasone/salmeterol is an inhaled glucocorticoid and long acting beta2 adrenergic agonist combination inhalation medication that is used for daily management of asthma. It is not a rescue medication. An adverse effect of the medication is oropharyngeal candidiasis. The nurse should instruct the client to gargle after each use, use a spacer to reduce the amount of drug in the mouth and throat, and report any white patches inside the mouth or on the tongue to the provider.

A nurse in a PACU is admitting a client who is postoperative following a tonsillectomy. Which of the following actions should the nurse plan to take to prevent aspiration? Place a bedside humidifier at the head of the client's bed. Suction the nasopharynx as needed. Withhold fluids until the client demonstrates a gag reflex. Perform chest physiotherapy.

Withhold fluids until the client demonstrates a gag reflex. Following a tonsillectomy, the client's gag reflex can be suppressed by local anesthetics or edema. To prevent aspiration, the gag reflex must be present before the client is allowed have fluids.