While checking the vital signs of a 10-year-old child who underwent a tonsillectomy earlier in the day, the nurse notices the child swallowing every 2 to 3 minutes. What action should the nurse take next?
Check for signs of teeth clenching or grinding
Inspect the back of the throat
Stimulate the gag reflex by touching the tonsillar pillars
Ask the child to speak to assess for any changes in voice tone .
The Correct Answer is B
Choice A rationale
Checking for signs of teeth clenching or grinding is not typically necessary in a child who has undergone a tonsillectomy and is swallowing frequently. These signs are not typically associated with post-tonsillectomy complications.
Choice B rationale
Inspecting the back of the throat is an appropriate action for the nurse to take next. Frequent swallowing can be a sign of bleeding in the throat, which is a potential complication of tonsillectomy. By inspecting the back of the throat, the nurse can assess for signs of bleeding.
Choice C rationale
Stimulating the gag reflex by touching the tonsillar pillars is not typically necessary in a child who has undergone a tonsillectomy and is swallowing frequently. This action could potentially cause discomfort or induce vomiting.
Choice D rationale
Asking the child to speak to assess for any changes in voice tone is not typically necessary in a child who has undergone a tonsillectomy and is swallowing frequently. Changes in voice tone are not typically associated with post-tonsillectomy complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While physical therapy can be beneficial for many pediatric patients, it may not be the most appropriate intervention for a newborn who has had gastroschisis repair and is on parenteral nutrition and continuous enteral feedings. The focus at this stage should be on promoting normal growth and development, and physical therapy may not directly contribute to this goal.
Choice B rationale
Offering a pacifier for non-nutritive sucking can be an effective strategy to promote normal growth and development in infants who have had gastroschisis repair. Non-nutritive sucking can help stimulate the sucking reflex, which is important for feeding and growth. Therefore, the nurse should include this action in the plan of care.
Choice C rationale
Confirming the placement of the enteral tube with an abdominal x-ray is an important part of care for infants on continuous enteral feedings. However, this action is more related to ensuring the safety and effectiveness of the feeding process rather than promoting the infant’s normal growth and development.
Choice D rationale
Using sterile technique during feedings is a standard practice to prevent infection, especially in infants who are on parenteral nutrition and continuous enteral feedings. However, this action does not directly promote the infant’s normal growth and development.
Correct Answer is ["1.8"]
Explanation
Step 1: Calculate the total dose of diazepam for this child by multiplying the child’s weight (30 kg) by the prescribed dose (0.3 mg/kg). This calculation gives a total dose of 9 mg (30 kg × 0.3 mg/kg = 9 mg).
Step 2: Divide the total dose (9 mg) by the concentration of the medication (5 mg/mL) to determine the volume to be administered. This calculation gives a volume of 1.8 mL (9 mg ÷ 5 mg/mL = 1.8 mL).
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