Four hours after rhinoplasty, a client is swallowing repeatedly. Which priority action should the practical nurse (PN) take?
Evaluate return of gag reflex.
Demonstrate relaxation techniques.
Use penlight to assess pharynx for bleeding.
Administer intravenous analgesic per PRN protocol.
The Correct Answer is C
Choice A reason: Evaluating the return of the gag reflex is important for assessing a client's ability to protect their airway and for readiness to eat or drink after surgery. However, it is not the immediate priority when a client is repeatedly swallowing, which can indicate bleeding.
Choice B reason: Demonstrating relaxation techniques can be beneficial for managing pain and anxiety, but it does not address the immediate concern of potential postoperative bleeding in a client who is repeatedly swallowing.
Choice C reason: Using a penlight to assess the pharynx for bleeding is the priority action. Repeated swallowing after rhinoplasty can indicate bleeding, and assessing the pharynx allows the nurse to identify and address any postoperative hemorrhage promptly.
Choice D reason: Administering an intravenous analgesic per PRN protocol may help manage pain, but it is not the priority action. The primary concern is to check for potential bleeding, which is indicated by the repeated swallowing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Yellow urine can be a sign of dehydration or other conditions, but it is not typically associated with cholelithiasis. While it is important to monitor urine color, it does not indicate a direct complication of gallstones.
Choice B reason: Restlessness can be caused by various factors, including discomfort or anxiety. However, it is not a specific indicator of a complication related to cholelithiasis. The practical nurse should assess the cause of restlessness, but it does not warrant immediate reporting to the charge nurse in the context of gallstones.
Choice C reason: Persistent nausea can be a symptom of cholelithiasis, especially if the gallstones are causing a blockage in the bile ducts. While nausea should be monitored and managed, it is not the most critical finding that requires immediate reporting to the charge nurse.
Choice D reason: Clay-colored stools are a significant finding that indicates a possible bile duct obstruction. When bile flow is blocked, it can result in pale or clay-colored stools. This is a critical sign that requires immediate attention and reporting to the charge nurse, as it suggests a serious complication that needs prompt intervention.
Correct Answer is ["B","C","D"]
Explanation
Choice A reason: Carrying the phone number of the Epilepsy Foundation at all times is helpful for accessing support and information, but it does not directly prevent seizure episodes. It is more of an additional resource rather than a preventive measure.
Choice B reason: Staying well rested and avoiding a large caffeine intake is crucial for managing seizure disorders. Lack of sleep and excessive caffeine can trigger seizures in some individuals. Ensuring adequate rest and limiting caffeine consumption can help reduce the likelihood of seizure episodes.
Choice C reason: Avoiding flashing lights and excessive visual stimuli is important for individuals with seizure disorders, as these can be potential triggers for seizures. Sensitivity to visual stimuli can lead to photosensitive epilepsy, making it essential to minimize exposure to such triggers.
Choice D reason: Seeking a safe place if sensing dizziness or sensory disturbances is vital for preventing injury during a seizure. Recognizing early warning signs and finding a safe environment can help protect the individual from harm during a seizure episode.
Choice E reason: Generic medications are generally considered safe to substitute for trade name brands, but it is essential to consult with a healthcare provider before making any changes to medication. Ensuring consistency in medication and avoiding abrupt changes is crucial for managing seizure disorders effectively.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.