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 B
Explanation
The American Academy of Pediatrics (AAP) and the Centers for Disease Control and Prevention (CDC) recommend that the first dose of MMR vaccine be given at 12-15 months of age.
A. 6 months is too early for the MMR vaccine.
D. 2 months is also too early for the MMR vaccine.
C. 24 months is slightly beyond the recommended range for the first dose of MMR vaccine, which is given between 12-15 months of age.
Correct Answer is C
Explanation
The nurse should reassure the parents that febrile seizures typically decrease in frequency as the child grows older. Most children outgrow febrile seizures by the age of 5 years.
Ibuprofen is not typically used prophylactically to prevent febrile seizures.
Providing the child with a sponge bath for temperatures over 100.6°F (38.1° C) can help to lower the fever, but it will not necessarily prevent febrile seizures.
Avoiding excessive visual stimuli is not necessary for children with febrile seizures, as this type of seizure is triggered by a fever rather than visual stimuli.
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