The nurse is caring for a client who has just returned from surgery. The client is asking for fluids due to thirst. What should the nurse assess before providing the client with fluids?
1. Ability to ambulate
2. Urine output
3. Return of the client's gag reflex
4. Ability to sit up
Answer: 3
1. The ability to ambulate will not prevent aspiration of fluids.
2. Urine output measures the client's fluid status, not the ability to swallow.
3. Anesthesia depresses the client's gag reflex. In order to prevent pneumonia from aspiration of fluids, the nurse ensures that the client's gag reflex has returned.
4. The head of the client's bed can be elevated in order for the client to drink fluids. This is not done until the gag reflex has returned.
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