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.

Question

Quizplus · Accepted Answer

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.

The PACU Nurse Is Informed That the Client Being Admitted