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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: Flushed, hot skin is not directly related to the client's CBC results. This symptom can indicate various conditions, such as fever, inflammation, or an allergic reaction, but it does not specifically correlate with the lab findings provided. The client's WBC count, hemoglobin, hematocrit, and basophils are within normal ranges, and the most significant abnormality is the low platelet count.
Choice B reason: Hives, or urticaria, are typically associated with allergic reactions and not directly related to the client's CBC results. While a low platelet count can sometimes be associated with immune-mediated conditions, hives are not a primary symptom of thrombocytopenia (low platelet count). The main concern with a low platelet count is the increased risk of bleeding and bruising.
Choice C reason: Inelastic turgor is a sign of dehydration or poor skin elasticity, often seen in conditions such as severe dehydration or malnutrition. The client's CBC results do not indicate dehydration or issues with skin turgor. The hemoglobin and hematocrit levels are within normal ranges, suggesting that the client's overall fluid status is likely stable.
Choice D reason: Bruising is the most relevant finding to assess for in a client with a low platelet count (thrombocytopenia). Platelets play a crucial role in blood clotting, and a low platelet count increases the risk of bleeding and easy bruising. The client's platelet count of 98,000/mm³ (98 x 10⁹/L) is below the normal range, which predisposes them to bruising and potential bleeding complications. It is important for the practical nurse to assess for signs of bruising and bleeding and to monitor the client closely for any further complications.

A. Use a large cuff to obtain BP readings on either thigh. B. Measure all vital signs every 2 hours except the BP. C. Obtain manual BP readings with a cuff on the left arm. D. Quickly release air from BP cuff on the right arm.

Correct Answer is A

Explanation

Choice A reason: Using a large cuff to obtain BP readings on either thigh is the appropriate action. With a history of a right radical mastectomy, blood pressure should not be taken on the right arm due to the risk of lymphedema. The left arm is also not suitable due to the recent surgery and cast. Therefore, the thigh is the best alternative site for accurate BP measurement.
Choice B reason: Measuring all vital signs every 2 hours except the BP is not appropriate because BP is a critical vital sign that needs to be monitored regularly, especially in postoperative clients. Omitting BP measurements could miss important changes in the client's condition.
Choice C reason: Obtaining manual BP readings with a cuff on the left arm is not recommended as the client has a recent surgical repair and cast on the left arm. This can cause discomfort and may not provide accurate readings.
Choice D reason: Quickly releasing air from the BP cuff on the right arm is not suitable due to the client's history of right radical mastectomy. This practice could exacerbate the risk of developing lymphedema in the affected arm.

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Four hours after rhinoplasty, a client is swallowing repeatedly. Which priority action should the practical nurse (PN) take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A client with a history of a right radical mastectomy arrives on the postoperative unit following surgical repair of a fractured left radius and application of a short arm cast. Which action should the practical nurse implement while obtaining the client's blood pressure (BP)?

Correct Answer is A

Explanation

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