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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. “I will rest my hand over my abdomen to create resistance.” This technique is used for diaphragmatic breathing exercises, not incentive spirometry. It does not help assess or improve lung expansion, which is the primary goal of using the incentive spirometer.
B. “I will lie on my back with my knees bent.” While lying down may be appropriate for some breathing exercises, the incentive spirometer is best used in a sitting or upright position. Sitting allows for maximal lung expansion and facilitates more effective use of the device.
C. “I will place the adapter on my finger to read my blood oxygen saturation level.” This describes the use of a pulse oximeter, not an incentive spirometer. The spirometer measures inspiratory volume, while pulse oximetry is used to monitor oxygen saturation.
D. "I will take in a deep breath and hold it before exhaling." The client should inhale slowly and deeply through the mouthpiece, hold the breath for several seconds to promote alveolar inflation, then exhale. This process helps prevent atelectasis and promotes lung expansion.
Correct Answer is ["42"]
Explanation
Calculation:
Total volume to be infused = 250 mL.
- Identify the infusion time and convert it to minutes.
Infusion time = 1.5 hours
Infusion time in minutes = 1.5 hours × 60 minutes/hour
= 90 minutes..
Drop factor = 15 gtt/mL.
- Calculate the flow rate in milliliters per minute (mL/minute).
Flow rate (mL/minute) = Total volume (mL) / Infusion time (minutes)
= 250 mL / 90 minutes
= 2.7777 mL/minute.
- Calculate the flow rate in drops per minute (gtt/minute).
Flow rate (gtt/minute) = Flow rate (mL/minute) × Drop factor (gtt/mL)
= 2.7777 mL/minute × 15 gtt/mL
= 41.6666 gtt/minute.
- Round the answer to the nearest whole number.
= 42 gtt/minute.
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