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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Verapamil is a calcium channel blocker that can lower the heart rate and blood pressure. A normal pulse rate for adults is between 60 and 100 beats per minute. A pulse rate of 48/min is too low and indicates bradycardia, which can cause dizziness, fainting, or cardiac arrest. Verapamil should not be given to patients with bradycardia or heart block.

Choice A is wrong because blood pressure 170/82 mm Hg is high and verapamil can help lower it. A normal blood pressure for adults is less than 120/80 mm Hg.

Choice B is wrong because respiratory rate 18/min is normal and verapamil does not affect it. A normal respiratory rate for adults is between 12 and 20 breaths per minute.

Choice D is wrong because potassium 4 mEq/L is normal and verapamil does not affect it. A normal potassium level for adults is between 3.5 and 5.0 mEq/L.

A. Contact information for a community mental health center. B. A list of primary prevention activities. C. Contact information for enrollment in a 12-step program. D. A referral for respite care services.

Correct Answer is A

Explanation

Contact information for a community mental health center. A community mental health center can provide ongoing outpatient care and support services for a client who has schizophrenia after discharge from an inpatient unit. A community mental health center can also help the client access other resources such as medication, housing, and vocational training.

Choice B is wrong because a list of primary prevention activities is not relevant for a client who already has schizophrenia. Primary prevention aims to prevent the occurrence of a disease or disorder in the first place.

Choice C is wrong because contact information for enrollment in a 12-step program is not appropriate for a client who has schizophrenia unless they also have a substance use disorder. A 12-step program is a self-help group that follows a set of principles to achieve and maintain sobriety.

Choice D is wrong because a referral for respite care services is not necessary for a client who has schizophrenia unless they also have a caregiver who needs temporary relief from their caregiving duties. Respite care services provide short-term care for clients who are dependent on others for their daily needs.

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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?

Nursing Test Bank

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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?