A nurse is caring for a preschooler immediately following a tonsillectomy and notices the child swallowing frequently.
Which of the following actions should the nurse take?
Check the back of the throat with a pen light.
Obtain the child’s vital signs in 15 min.
Administer analgesia.
Offer the child a drink of water.
The Correct Answer is C
Administer analgesia. The child is likely experiencing pain and discomfort after the tonsillectomy, which can cause frequent swallowing. Analgesia can help relieve the pain and reduce the risk of bleeding.
Choice A is wrong because checking the back of the throat with a pen light can cause trauma and bleeding to the surgical site. The nurse should avoid using any instruments or objects in the mouth of the child after a tonsillectomy.
Choice B is wrong because obtaining the child’s vital signs in 15 min is not a priority action. The nurse should monitor the child’s vital signs more frequently, especially for signs of bleeding such as increased pulse and decreased blood pressure.
Choice D is wrong because offering the child a drink of water can cause irritation and bleeding to the throat. The nurse should avoid giving the child any fluids or foods by mouth until the gag reflex returns and the child is fully awake. The nurse should also avoid giving the child any fluids or foods that are acidic, carbonated, hot, or spicy, as they can cause pain and bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Encourage the client to visit with someone who has had an amputation.
This strategy can help the client cope with the loss of a body part and learn from the experience of others who have gone through a similar situation.
Choice A is wrong because suggesting that the client wear facility clothing until the prosthesis fitting can delay the client’s acceptance of the body image alteration and increase the risk of infection.
Choice C is wrong because discouraging the client from touching the residual limb for the first week can interfere with the healing process and prevent the client from becoming familiar with the new body part.
Choice D is wrong because reassuring the client that the rehabilitation program is optional can discourage the client from participating in physical therapy and hinder the recovery and adaptation.
Correct Answer is D
Explanation
The nurse should determine if the client has prepared their advance directives, which are legal documents that specify the client’s wishes regarding medical care in case they become incapacitated. Advance directives can include a living will, a durable power of attorney for health care, or a do-not-resuscitate order. The nurse should respect the client’s autonomy and right to self-determination by asking about their advance directives and ensuring that they are documented and followed.
Choice A is wrong because the nurse should not delay the admission while the client fills out the facility’s advance directives form.
The client has the right to refuse or accept any treatment, including filling out an advance directives form.
The nurse should inform the client about the benefits of having advance directives, but should not coerce or pressure them to complete one.
Choice B is wrong because the nurse should not confirm with the client’s family that the consent form has been signed.
The consent form is a legal document that indicates that the client has given informed consent for the surgery, which means that they have received adequate information about the procedure, its risks and benefits, and alternative options.
The consent form should be signed by the client, unless they are a minor, mentally incompetent, or unable to communicate.
The nurse should verify that the consent form has been signed by the client or their legal representative before the surgery.
Choice C is wrong because the nurse should not explain to the client that signing the facility’s consent form means they cannot refuse care.
Signing the consent form does not waive the client’s right to withdraw consent at any time before or during the surgery.
The nurse should inform the client that they can change their mind and refuse care at any point, and that their decision will be respected and honored.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today