4 the nurse is caring for a 20 year old patient who

4.
The nurse is caring for a 20-year-old patient who recently underwent a tonsillectomy. The
patient is fully awake and clearing his throat frequently but denies pain. Which action is most
important for the nurse to take first?
a. Place the patient in a side-lying position.
b. Look in the patient’s mouth.
c. Offer the patient a grape popsicle.
d. Remove the straw from the patient’s tray.
ANS: B
Frequent swallowing or clearing of the throat may indicate bleeding. Further assessment is
indicated, and the nurse should look in the patient’s mouth to assess for bleeding.
The fully alert adult patient should be placed in semi-Fowler position to ensure adequate
ventilation. Offering the patient a grape popsicle is an appropriate intervention once the nurse
confirms that the patient is not bleeding. While removing the straw from the tray is an
appropriate intervention to prevent bleeding that may result from sucking, the nurse should
first ensure that the patient is not currently bleeding.
MEDICAL SURGICAL NURSING CONCEPTS AND PRACTICE 3RD EDITION DEWIT TEST BANK
PTS: 1 DIF: Cognitive Level: Analysis REF: 278
OBJ: 1 (theory) TOP: Positioning After Tonsillectomy
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
5.
The nurse is caring for a patient with sleep apnea. The patient complains that he is constantly
fatigued. Which response is most appropriate for the nurse to make?
PTS: 1 DIF: Cognitive Level: Application REF: 279
OBJ: 1 (theory) TOP: Sleep Apnea KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
6.
The nurse is caring for a patient during the immediate postoperative period following a
rhinoplasty. Which finding is most concerning to the nurse?
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