The PACU nurse is informed that the client being admitted has not recovered his pharyngeal reflex. The nursing action that should receive greatest priority is to
a. check for the gag reflex frequently.
b. maintain an oral airway.
c. remain with the client at all times.
d. suction the client frequently.
C
Clients admitted to the PACU without pharyngeal (gag) reflex are positioned on their side. The immediate assessment includes the ABCs: airway, breathing, circulation. An impaired gag reflex could impair breathing. The nurse stays at the bedside until the client's pharyngeal reflex returns. The nurse would monitor for return of the reflex and would be prepared to suction the client's secretions if needed. An oral airway may or may not be used.
You might also like to view...
Why is it important to examine individual familial health/HEALTH practices?
A. Helps a person become sensitized to understand the role that ethnocultural and religious heritage has played within a family B. Identifies what healing practices need to be used when one is ill C. Rejects those health traditions if they differ from those of the same ethnocultural group D. Generalizes to all members of the same ethnocultural group the various health practices that are done
Why is end-of-life planning often neglected? (Select all that apply.)
a. There is a clear procedure to follow. b. People are uncomfortable talking about death. c. Young people do not see the need for end-of-life planning. d. End-of-life planning is a relatively new concept. e. Many persons are not really sure what they want to do.
In which of the following situations could the care of a patient be transferred to an unregulated care provider?
a. The patient's condition is well-controlled or managed. b. The patient's condition is expected to change. c. The patient is unresponsive. d. The patient's response to the procedure is unpredictable.
What is the most appropriate explanation as to why dipivefrin hydrochloride (Propine) effectively decreases intraocular pressure?
1. The exact mechanism is not fully understood. 2. It decreases the formation of aqueous humor. 3. It reduces plasma volume very quickly. 4. It converts to epinephrine and increases outflow of aqueous humor.