The nurse is caring for a client who just had a bronchoscopy performed and is asking for a drink of water, reporting that his mouth feels very dry. The nurse:
1. Gets the client a small glass of water to sip on.
2. Informs the client he is not allowed to have water.
3. Tests the client's gag and swallow reflexes.
4. Uses a lemon glycerine swab to moisten the oral cavity.
3
Rationale: The nursing process always begins with assessment, so the nurse will assess to determine whether the client has intact gag and swallow reflexes first. Even a lemon glycerine swab could result in aspiration if the client's reflexes are absent.
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