When caring for a patient that has undergone a tonsillectomy, the nurse's priority assessment in identifying a potential complication would include?

Assess breathing pattern for snoring.

Assess mucous membranes for moisture.

Assess pain level.

Observe for continuous swallowing.

Answer and Explanation

The Correct Answer is D

A.   While changes in breathing patterns can indicate airway obstruction, snoring alone is not the most specific indicator of a complication after tonsillectomy. It could indicate swelling or an obstructed airway but does not specifically indicate bleeding.

B.   Checking the mucous membranes for moisture is important in general nursing care to assess hydration status. However, it is not the most immediate priority in the post-tonsillectomy setting, where the primary concern is to monitor for bleeding.
C.   Assessing pain is important for overall patient comfort and to evaluate the effectiveness of pain management strategies. However, pain alone does not directly indicate a complication like bleeding, which is a critical concern in this scenario.
D.   Continuous swallowing can be an early sign of bleeding after tonsillectomy, as patients may swallow frequently to clear blood from the throat. If a patient is swallowing more often than normal, it could indicate that they are swallowing blood, which would require immediate intervention.

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Correct Answer is D

Explanation

A. While it may be important to inform the parents later, this is not the immediate priority. The first step should be to assess and manage the current situation before involving the parents.
B. This is a reasonable action to help soothe the itching and irritation caused by contact dermatitis. However, before applying compresses, it’s crucial to ensure that the area is clean and that there is no potential for worsening the condition.
C. This may be necessary if the reaction is severe or worsening, but in this case, the student is exhibiting signs consistent with contact dermatitis, which can often be managed effectively at school without immediate medical intervention.
D. Washing the affected area with soap and water helps remove any potential irritants or allergens that may be causing the dermatitis. This action can help prevent the condition from worsening and relieve some of the symptoms.

A. Glycosylated hemoglobin (Hgb A1C) level of 7.5 B. Random plasma glucose level of 205 C. A blood glucose prior to the noon meal of 45 D. Fasting blood glucose level of 300.

Correct Answer is C

Explanation

A. This level indicates average blood glucose over the past 2-3 months and is higher than the target range (usually under 7% for many patients with diabetes). While this result suggests the need for adjustments in management, it is not an immediate emergency.
B. A random plasma glucose level of 205 mg/dL indicates hyperglycemia, but it is not typically considered an immediate danger unless accompanied by symptoms of hyperglycemia. This level would warrant further monitoring and possibly an adjustment in treatment, but it doesn't require urgent intervention.
C. A blood glucose level of 45 mg/dL indicates hypoglycemia, which is a critical condition that requires immediate action. Hypoglycemia can lead to symptoms such as confusion, seizures, or loss of consciousness, and it must be addressed quickly, usually with fast-acting carbohydrates.
D. While a fasting blood glucose level of 300 mg/dL indicates significant hyperglycemia, it does not require immediate action like hypoglycemia does. This level indicates a need for further management but is not acutely dangerous compared to a severely low blood glucose level.

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When caring for a patient that has undergone a tonsillectomy, the nurse's priority assessment in identifying a potential complication would include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

Which test results require the most immediate action by the nurse?

Correct Answer is C

Explanation

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