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 .

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale
While a fever could indicate an infection or other illness, it is not the most concerning symptom in a child with croup. Croup is primarily a respiratory condition, and symptoms related to breathing difficulties are generally of greater concern.
Choice B rationale
A barking cough is a common symptom of croup, but it is not typically the primary concern for a telephone triage nurse. While it can be distressing, it is not usually a sign of a severe or life-threatening condition.
Choice C rationale
Frequent crying during nursing could indicate discomfort or distress, but it is not the most concerning symptom in a child with croup. Croup primarily affects the respiratory system, and symptoms related to breathing difficulties are generally of greater concern.
Choice D rationale
Difficulty swallowing secretions is the most concerning symptom in a child with croup. This could indicate severe swelling of the airway, which could potentially lead to breathing difficulties and require immediate medical attention.

A. Position prone after feeding. B. Breastfeed frequently. C. Avoid smoke exposure. D. Inspect the infant’s ears daily.

Correct Answer is C

Explanation

Choice A rationale
Positioning the infant prone after feeding is not recommended as it can increase the risk of sudden infant death syndrome (SIDS) and does not specifically prevent otitis media.
Choice B rationale
While breastfeeding has many health benefits, it is not specifically linked to the prevention of otitis media recurrence.
Choice C rationale
Avoiding smoke exposure is a key recommendation for preventing otitis media recurrence in infants. Secondhand smoke can irritate the eustachian tubes and contribute to fluid build-up in the middle ear, increasing the risk of otitis media.
Choice D rationale
Inspecting the infant’s ears daily is not a specific recommendation for preventing otitis media recurrence. While regular check-ups can help detect any issues early, they do not prevent the recurrence of otitis media.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When advising a new mother on caring for a child with croup, which symptom should be a priority concern for the telephone triage nurse?

Correct Answer is D

Explanation

The nurse is providing education to parents about preventing otitis media recurrence in their infant. Which instruction should the nurse include?

Correct Answer is C

Explanation

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?

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