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 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.
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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