After a tonsillectomy, a 7-year-old girl begins to swallow excessively.
Which intervention is most important for the practical nurse to implement?
Inform the registered nurse about the vital signs and swallowing.
Offer the child fluids to soothe the throat.
Administer supplemental oxygen per prescription.
Elevate the child's head to promote drainage.
The Correct Answer is A
Choice A rationale
Excessive swallowing after a tonsillectomy is a critical sign of postoperative hemorrhage, as blood pooling in the pharynx triggers the swallowing reflex. Promptly informing the registered nurse allows for immediate assessment, potential intervention to control bleeding, and prevention of airway compromise or hypovolemic shock.
Choice B rationale
Offering fluids to soothe the throat is contraindicated in suspected hemorrhage as it may increase the risk of aspiration or obscure the amount of blood being swallowed. It also delays the critical assessment and intervention required for active bleeding.
Choice C rationale
Administering supplemental oxygen per prescription is a supportive measure for respiratory distress. While potentially necessary if the child's oxygen saturation drops, it does not address the underlying cause of excessive swallowing, which is likely hemorrhage, and should not be prioritized over reporting the cardinal sign.
Choice D rationale
Elevating the child's head to promote drainage is a general comfort measure and may help with swelling. However, it does not directly address active bleeding. In a suspected hemorrhage, the primary concern is to identify and manage the source of bleeding, not merely to promote drainage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["25"]
Explanation
Step 1 is: Subtract the dry diaper weight from the wet diaper weight to find the weight of the urine. 75 grams - 50 grams = 25 grams.
Step 2 is: Convert the weight of the urine from grams to milliliters, as 1 gram of urine is approximately equal to 1 mL. 25 grams = 25 mL. The urine output is 25 mL.
Correct Answer is D
Explanation
Gravida refers to the total number of pregnancies a woman has had, regardless of outcome. The client has had a pregnancy that resulted in a miscarriage at 16 weeks, a pregnancy that resulted in fetal demise at 31 weeks, and the current pregnancy at 39 weeks. Therefore, the total number of pregnancies is 3. The gravida is 3.
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