While obtaining the vital signs of a 10-year-old child who had a tonsillectomy this morning, the nurse observes the child swallowing every 2 to 3 minutes.
Which assessment should the nurse implement?
Inspect the posterior oropharynx.
Touch the tonsillar pillars to stimulate the gag reflex.
Ask the child to speak to evaluate change in voice tone.
Assess for teeth clenching or grinding.
The Correct Answer is A
The nurse should inspect the posterior oropharynx of a child who is frequently swallowing after tonsillectomy to assess for bleeding or the presence of clots. Swallowing frequently can be a sign of postoperative bleeding, which is a potential complication of tonsillectomy.
Touching the tonsillar pillars to stimulate the gag reflex or asking the child to speak would not provide information about the presence of bleeding.
Assessing for teeth clenching or grinding is not related to this particular observation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.3"]
Explanation
1.3 mL of amoxicillin suspension with each dose.
To calculate the correct dose of amoxicillin to give to the child, follow these steps:
Step 1: Convert the child's weight from pounds to kilograms. 18 pounds ÷ 2.2 = 8.18 kilograms
Step 2: Calculate the total daily dose of amoxicillin. 25 mg/kg/day x 8.18 kg = 204.5 mg/day
Step 3: Divide the total daily dose into two equal doses to be given every 12 hours. 204.5 mg/day ÷ 2 doses = 102.25 mg/dose
Step 4: Determine how many mL of the suspension contain 102.25 mg of amoxicillin. 400 mg/5 mL = 80 mg/mL 102.25 mg ÷ 80 mg/mL = 1.28 mL
Correct Answer is D
Explanation
Aortic stenosis is a narrowing of the aortic valve, which can cause decreased blood flow from the left ventricle to the systemic circulation. In infants with aortic stenosis, the left ventricle must work harder to pump blood through the narrowed valve, which can lead to left ventricular hypertrophy, heart failure, and pulmonary edema. Bilateral fine crackles in both lung fields may indicate fluid overload in the lungs, which is a common complication of heart failure. Hypotension and tachycardia may also be present due to decreased cardiac output.
Option A is not a typical finding associated with aortic stenosis.
Option B is not directly related to the infant's cardiac condition.
Option C is not a typical finding associated with heart failure.
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