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 adolescent's symptoms suggest that their blood glucose levels may be very high. Obtaining a point-of- care glucose reading is the first step in assessing the adolescent's current blood glucose levels and determining the appropriate course of action.
Reviewing prior insulin prescriptions, assessing urine for ketones, and checking blood pressure are also important interventions but should occur after the blood glucose level has been determined.
Correct Answer is C
Explanation
When advising a new mother on caring for a child with croup, the telephone triage nurse should prioritize concern for difficulty swallowing secretions. This symptom can indicate that the child's airway is becoming obstructed and requires immediate medical attention. A fever of 101.0°F (38.3°C) is a common symptom of croup and can be managed at home with antipyretics. Crying often when nursing is not a specific symptom of croup and may have other causes. A barking cough, worse at night, is a characteristic symptom of croup and can be managed at home with humidified air and hydration.
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