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 A
Explanation
The nurse should report a positive rapid strep test of the oropharynx to the healthcare provider. Acute glomerulonephritis is often caused by a recent streptococcal infection, and a positive rapid strep test would confirm this as the underlying cause
A blood pressure of 88/50 mmHg is within the normal range for a child and would not need to be reported.
A maculopapular rash over the trunk of the body is not typically associated with acute glomerulonephritis and would not need to be reported.
Weight loss may occur with acute glomerulonephritis due to decreased appetite, but it is not an urgent finding that needs to be reported immediately.
Correct Answer is B
Explanation
The client should be instructed to eat a source of sugar if he experiences profuse perspiration, which may indicate hypoglycemia or low blood sugar. Other symptoms of hypoglycemia include shakiness, confusion, dizziness, and weakness.
Eating a source of sugar, such as a glucose tablet, fruit juice, or candy, can quickly raise blood sugar levels and alleviate symptoms of hypoglycemia.
A racing pulse, excessive thirst, and seeing spots are not typically associated with hypoglycemia.
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