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
It occurs because nicotine stimulates the release of dopamine, a neurotransmitter that regulates mood and pleasure. When nicotine intake is stopped, dopamine levels drop and cause anxiety and irritability.
Choice A is wrong because tachycardia, or rapid heart rate, is not a symptom of nicotine withdrawal. In fact, smoking can increase blood pressure and heart rate, so quitting smoking may lower them.
Choice C is wrong because weight loss is not a symptom of nicotine withdrawal. On the contrary, weight gain is more likely to occur after quitting smoking, because nicotine suppresses appetite and increases metabolism.
Choice D is wrong because vomiting is not a symptom of nicotine withdrawal. Vomiting may be a side effect of some nicotine replacement therapies, such as patches or gum, but it is not caused by the lack of nicotine itself.
Correct Answer is D
Explanation
This action indicates that the charge nurse should intervene because adding food coloring to the tube feeding is not recommended and can cause adverse effects such as aspiration, diarrhea, and allergic reactions.
Choice A is wrong because checking the volume of the aspirate is a correct action to assess gastric residual volume and prevent complications such as nausea, vomiting, and aspiration.
Choice B is wrong because checking the pH of the aspirate is a correct action to verify the placement of the NG tube and prevent accidental administration of enteral feeding into the lungs.
Choice C is wrong because administering 15 mL of water before administering the feeding is a correct action to flush the NG tube and prevent clogging.
Normal ranges for gastric residual volume are less than 250 mL for adults and less than 5 mL/kg for children. Normal ranges for pH of gastric aspirate are less than 5.5 for adults and less than 4 for children.
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