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
A fecal-fat test is used to measure the body’s ability to break down and absorb fat. It is not used to screen for cystic fibrosis.
Choice B rationale
The sweat-chloride test is the standard diagnostic test for cystic fibrosis. This test measures the amount of chloride, a component of salt, in the sweat. People with cystic fibrosis have two to five times the normal amount of chloride in their sweat.
Choice C rationale
A pulmonary-function test measures how well the lungs are working and can be used to monitor the lung function in people already diagnosed with cystic fibrosis. However, it is not a standard screening test for cystic fibrosis.
Choice D rationale
A potassium chloride test is not used to screen for cystic fibrosis. Potassium chloride is a type of medication used to treat or prevent low amounts of potassium in the blood.
Correct Answer is D
Explanation
Choice D rationale
The nurse should instruct the mother to place the child in a quiet environment first. Kawasaki disease is an illness that can cause inflammation in the blood vessels and can lead to symptoms such as irritability and skin peeling. Placing the child in a quiet environment can help reduce stimulation and promote rest, which can help improve the child’s symptoms.
Choice A rationale
Applying lotion to hands and feet may help with the symptom of skin peeling, but it does not address the underlying issue of the child’s irritability or refusal to eat.
Choice B rationale
While it’s important for parents to rest when possible, this does not directly address the child’s symptoms.
Choice C rationale
Making a list of foods that the child likes could potentially help with the child’s refusal to eat, but it does not address the child’s irritability or skin peeling.
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