When caring for a patient that has undergone a tonsillectomy, the nurse's priority assessment in identifying a potential complication would include?
Assess breathing pattern for snoring.
Assess mucous membranes for moisture.
Assess pain level.
Observe for continuous swallowing.
The Correct Answer is D
A. While changes in breathing patterns can indicate airway obstruction, snoring alone is not the most specific indicator of a complication after tonsillectomy. It could indicate swelling or an obstructed airway but does not specifically indicate bleeding.
B. Checking the mucous membranes for moisture is important in general nursing care to assess hydration status. However, it is not the most immediate priority in the post-tonsillectomy setting, where the primary concern is to monitor for bleeding.
C. Assessing pain is important for overall patient comfort and to evaluate the effectiveness of pain management strategies. However, pain alone does not directly indicate a complication like bleeding, which is a critical concern in this scenario.
D. Continuous swallowing can be an early sign of bleeding after tonsillectomy, as patients may swallow frequently to clear blood from the throat. If a patient is swallowing more often than normal, it could indicate that they are swallowing blood, which would require immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Primary hypertension, also known as essential hypertension, is characterized by high blood pressure that does not have a known secondary cause. It accounts for the majority of hypertension cases and is thought to result from a combination of genetic, environmental, and lifestyle factors.
B. While treatment is important for all forms of hypertension to prevent complications, this statement is somewhat misleading. The term "essential" in primary hypertension refers to the lack of a specific identifiable cause, not that it is necessarily more critical to treat than other forms of hypertension.
C. This definition describes secondary hypertension, not primary hypertension. Secondary hypertension results from an identifiable underlying condition, such as kidney disease or hormonal disorders.
D. Primary hypertension can vary in severity, but it is not exclusively severe or life-threatening. While uncontrolled hypertension can lead to serious complications, primary hypertension itself does not automatically imply a critical state.
Correct Answer is B
Explanation
A. Ondansetron is not indicated for treating diarrhea. While nausea can accompany diarrhea, ondansetron specifically targets nausea and vomiting rather than the underlying causes of diarrhea.
B. Ondansetron is primarily used to prevent and treat nausea and vomiting, particularly those associated with chemotherapy, radiation therapy, and postoperative recovery. If a patient is experiencing nausea and vomiting, ondansetron would be the appropriate medication to administer.
C. Ondansetron is not indicated for managing pain. Incisional pain is typically treated with analgesics, not antiemetics. While postoperative patients may experience nausea, ondansetron would not be used solely for pain relief.
D. Paralytic ileus is a condition characterized by the lack of movement in the intestines, leading to a blockage. While nausea and vomiting can occur in this condition, ondansetron is not a treatment for the underlying issue of ileus. The focus would be on managing the ileus and any complications that arise.
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