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
The task involves making ongoing judgments about client data. This is a contraindication to delegating a task to an AP because the AP is not trained or authorized to make clinical decisions or assessments. The nurse is responsible for evaluating the client’s condition and needs, and delegating only tasks that are within the AP’s scope of practice and do not require critical thinking.
Choice B is wrong because the task is within the AP’s range of function to perform.
This is a criterion for delegating a task to an AP, not a contraindication. The nurse should ensure that the AP has the necessary skills and knowledge to perform the task safely and effectively.
Choice C is wrong because the task can be performed in the same manner for most clients.
This is also a criterion for delegating a task to an AP, not a contraindication. The nurse should delegate tasks that are routine, standardized, and have predictable outcomes.
Choice D is wrong because the task requires a specific sequence of steps.
This is not a contraindication to delegating a task to an AP, as long as the AP is competent and familiar with the procedure. The nurse should provide clear instructions and expectations for the task, and monitor the AP’s performance.
Correct Answer is D
Explanation
Bleach.
According to the CDC, bleach is an effective disinfectant for environmental surfaces contaminated with blood or body fluids from a person with AIDS or other bloodborne pathogens. Bleach can kill HIV and hepatitis viruses when used in a 1:10 dilution with water.
Choice A is wrong because isopropyl alcohol is not recommended for disinfecting environmental surfaces. It can evaporate quickly and may not have enough contact time to kill the pathogens.
Choice B is wrong because chlorhexidine is an antiseptic, not a disinfectant. It is used for skin cleansing or wound irrigation, but it is not effective against spores or non-enveloped viruses.
Choice C is wrong because hydrogen peroxide is a low-level disinfectant that can be inactivated by organic matter.
It is not suitable for disinfecting surfaces contaminated with blood or body fluids.
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