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Difficulty: EasyBasic Care and Comfort

Upon receiving a lethargic client from the post-anesthesia care unit following a tonsillectomy, the practical nurse must establish a safe resting position. Which positioning strategy should the nurse use to facilitate the drainage of oral secretions and prevent aspiration?

  1. Side-lying position with the head slightly elevatedAnswer
  2. B
    Supine position with the neck slightly hyperextended
  3. C
    Semi-Fowler's position with a pillow firmly under the shoulders
  4. D
    Flat on the back with the legs elevated on a pillow

Answer

The side-lying position with the head slightly elevated is the correct choice to protect the airway.
The correct positioning strategy utilizes a side-lying posture. This is a fundamental basic care measure because it uses gravity to facilitate the natural drainage of saliva and potential bleeding out of the mouth. This is especially critical while the client remains lethargic from anesthesia and lacks intact airway clearance reflexes.

Step-by-Step Solution

1
Identify the client's current physiological status and primary risks.
The client is lethargic from anesthesia and has just undergone oral surgery (tonsillectomy).
Recognizing the altered level of consciousness and surgical site highlights a severe risk for aspiration of blood and saliva.
2
Determine the physical principles necessary for airway clearance.
Gravity must be used to move fluids outward rather than allowing them to pool in the back of the throat.
A lethargic client cannot reliably swallow or clear their own airway through coughing.
3
Select the position that best utilizes gravity for drainage.
A side-lying (lateral) or partially prone position naturally directs fluids out of the mouth.
This positioning strategy prevents the accumulation of secretions over the trachea, ensuring safe basic care and comfort.

Key Concept

Postoperative Positioning for Airway Protection
Estimated Time:45s
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Topics

Basic Care and Comfort

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