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 A
A. Frequent swallowing after a tonsillectomy may indicate postoperative bleeding. The nurse should check the back of the throat with a pen light to assess for signs of hemorrhage.
B. While obtaining vital signs is important, it does not directly address the concern of potential bleeding.
C. Administering analgesia is appropriate for pain management but does not address the priority concern of bleeding.
D. Offering water could potentially worsen bleeding if it is occurring and should not be the first action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Offer the client fluids high in fiber and protein every hour. This is because clients who have bipolar disorder and are experiencing mania are at risk of dehydration, malnutrition, and weight loss due to increased activity, poor intake, and impaired judgment. Fluids high in fiber and protein can help prevent constipation and promote satiety.
Choice B is wrong because monitoring the client’s vital signs twice per day is not enough for a client who has mania. The nurse should monitor the client’s vital signs more frequently, at least every 4 hours, to assess for signs of dehydration, infection, or cardiac complications.
Choice C is wrong because encouraging the client to participate in group therapy activities each day can increase the client’s stimulation and agitation. The nurse should provide a calming environment with fewer stimuli and solitary activities for a client who has mania.
Choice D is wrong because weighing the client three times per week is not sufficient for a client who has mania. The nurse should weigh the client daily to monitor for weight loss and fluid imbalance.
Correct Answer is B
Explanation
Verapamil is a calcium channel blocker that can lower blood pressure and cause dizziness or fainting, especially when standing up from a sitting or lying position. Changing positions slowly can help prevent these symptoms.
Choice A is wrong because palpitations are not an expected side effect of verapamil, but rather a sign of a possible overdose or a serious heart problem that requires medical attention.
Choice C is wrong because verapamil should be taken with food or milk to avoid stomach upset and increase absorption.
Choice D is wrong because verapamil does not cause weight loss, but rather weight gain as a possible side effect.
Increasing calorie intake is not necessary and may worsen other health conditions such as diabetes or high cholesterol.
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