The nurse is caring for a 20-year-old patient who recently had a tonsillectomy. The patient is fully awake and frequently clears his throat, but denies experiencing any pain. What is the most important action for the nurse to take first?

Assess the posterior pharynx for active bleeding.

Place the client in the side lying position.

Give the client juice through a straw.

Offer the client ice cream to coat the throat.

Answer and Explanation

The Correct Answer is A

A. Assess the posterior pharynx for active bleeding: Frequent throat clearing without reported pain after a tonsillectomy may indicate active bleeding, which can be life-threatening. Silent bleeding may drip down the throat and trigger subtle clearing rather than coughing or spitting, making visual inspection an immediate priority.

B. Place the client in the side lying position: Side-lying can help prevent aspiration if bleeding occurs, but it does not replace the need to directly assess for bleeding first. Positioning should follow an initial airway and bleeding assessment.

C. Give the client juice through a straw: Using a straw is discouraged after tonsillectomy because the suction motion can disrupt clots and provoke bleeding. Juice may be appropriate for hydration, but not with a straw and not before checking for bleeding.

D. Offer the client ice cream to coat the throat: Cold soft foods like ice cream may soothe the throat and reduce swelling, but this should not be the first action when silent bleeding is suspected. The priority is ensuring that no active bleeding is occurring before offering food.

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Correct Answer is A

Explanation

A. Use an N95 respirator when entering the room:An N95 respirator provides a tight seal and filters airborne particles, which is essential for preventing transmission of Mycobacterium tuberculosis. Because TB spreads through airborne droplets, wearing an N95 mask is the most important protection for healthcare workers.

B. Place the patient in a room with positive room airflow:Positive pressure airflow pushes air out of the room, which risks contaminating surrounding areas. TB patients must be placed in negative pressure rooms to contain and filter airborne pathogens safely within the room.

C. Open the windows in the room for extra ventilation:While increasing ventilation may reduce airborne concentration of pathogens in certain settings, it is not a recommended infection control method in clinical environments.

D. Use a surgical mask when entering the room:Surgical masks do not effectively filter small airborne particles like TB bacilli. They are intended for droplet precautions, not airborne precautions, and therefore offer inadequate protection for staff entering a TB patient's room.

A. The client's sputum is white colored B. The client's arterial blood gas CO2 level is 76 mm hg C. The client's pulse oximeter is 90%. D. The client has mild SOB when walking to the bathroom

Correct Answer is B

Explanation

A. The client's sputum is white colored:White sputum may be normal for a client with COPD and often indicates chronic inflammation without infection. It does not signal an acute or emergent issue that requires immediate intervention.

B. The client's arterial blood gas CO₂ level is 76 mm Hg:A CO₂ level this high indicates significant hypercapnia, which can lead to respiratory acidosis and altered mental status. This finding reflects serious respiratory compromise and requires prompt intervention to prevent respiratory failure.

C. The client's pulse oximeter is 90%:While 90% is on the lower end of acceptable for clients with end-stage COPD, it is often tolerated due to their adapted baseline. It does not represent an immediate threat unless accompanied by other signs of deterioration.

D. The client has mild SOB when walking to the bathroom:Mild shortness of breath with exertion is expected in clients with advanced COPD. It reflects baseline activity tolerance and does not require urgent action unless symptoms worsen.

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The nurse is caring for a 20-year-old patient who recently had a tonsillectomy. The patient is fully awake and frequently clears his throat, but denies experiencing any pain. What is the most important action for the nurse to take first?

Nursing Test Bank

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