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

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4.The nurse is caring for a 20-year-old patient who recently underwent a tonsillectomy. Thepatient is fully awake and clearing his throat frequently but denies pain. Which action is mostimportant 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: BFrequent swallowing or clearing of the throat may indicate bleeding. Further assessment isindicated, 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 adequateventilation. Offering the patient a grape popsicle is an appropriate intervention once the nurseconfirms that the patient is not bleeding. While removing the straw from the tray is anappropriate intervention to prevent bleeding that may result from sucking, the nurse shouldfirst ensure that the patient is not currently bleeding.MEDICAL SURGICAL NURSING CONCEPTS AND PRACTICE 3RD EDITION DEWIT TEST BANK
PTS: 1DIF:Cognitive Level: AnalysisREF: 278OBJ: 1 (theory)TOP: Positioning After TonsillectomyKEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Reduction of Risk Potential5.The nurse is caring for a patient with sleep apnea. The patient complains that he is constantlyfatigued. Which response is most appropriate for the nurse to make?
PTS: 1DIF:Cognitive Level: ApplicationREF: 279OBJ: 1 (theory)TOP: Sleep ApneaKEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physiological Adaptation6.The nurse is caring for a patient during the immediate postoperative period following arhinoplasty. Which finding is most concerning to the nurse?
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Term
Spring
Professor
Potter
Tags
Nursing, colds

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