A nurse is caring for a preschooler immediately following a tonsillectomy and notices the child swallowing frequently.
Which of the following actions should the nurse take?
Check the back of the throat with a pen light.
Obtain the child’s vital signs in 15 min.
Administer analgesia.
Offer the child a drink of water.
The Correct Answer is A
A. Frequent swallowing after a tonsillectomy may indicate postoperative bleeding. The nurse should check the back of the throat with a pen light to assess for signs of hemorrhage.
B. While obtaining vital signs is important, it does not directly address the concern of potential bleeding.
C. Administering analgesia is appropriate for pain management but does not address the priority concern of bleeding.
D. Offering water could potentially worsen bleeding if it is occurring and should not be the first action.
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Related Questions
Correct Answer is C
Explanation
A bone scan that is scheduled for today. The nurse should include this information in the change-of-shift report because the oncoming nurse might have to modify the client’s care to accommodate leaving the unit.
Choice A is wrong because the client’s input and output for the shift are routine data that can be found in the client’s chart and do not need to be verbally reported.
Choice B is wrong because the client’s blood pressure from the previous day is not relevant to the current condition of the client and does not reflect any changes or interventions.
Choice D is wrong because the medication routine from the medication administration record is also routine data that can be accessed by the oncoming nurse and does not indicate any special needs or concerns.
Correct Answer is C
Explanation
The HbA1c value determines long-term blood glucose control for the past 120 days. This is because the HbA1c test measures what percentage of hemoglobin proteins in your blood are coated with sugar (glycated). Hemoglobin proteins in red blood cells live for around 120 days, so the test reflects your average blood sugar level for the past two to three months.
Choice A is wrong because an HbA1c value greater than 8% indicates poor diabetic control of blood sugar. The HbA1c target for most people with type 1 diabetes is 48 mmol/mol (or 6.5%) or lower.
Choice B is wrong because the HbA1c value is not altered by eating habits the day before the test. The test does not require fasting and can be done at any time of the day.
Choice D is wrong because an HbA1c test should be performed more than once per year.
The frequency of the test depends on the type of diabetes, your treatment plan and your blood sugar level. For example, you may need the test twice a year if you have good blood sugar control, or four times a year if you take insulin or have trouble keeping your blood sugar level within your target range.
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