A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings should the nurse identify as the priority?
Sore throat
Dark brown emesis
Blood-tinged mucus
Frequent swallowing
The Correct Answer is D
A. Sore throat. This is incorrect because a sore throat is an expected postoperative finding following a tonsillectomy and does not indicate a complication.
B. Dark brown emesis. This is incorrect because dark brown emesis may be swallowed blood from surgery and is not necessarily an immediate concern unless it continues or turns bright red.
C. Blood-tinged mucus. This is incorrect because small amounts of blood-tinged mucus are normal after a tonsillectomy and do not indicate active bleeding.
D. Frequent swallowing. This is correct because frequent swallowing can indicate active bleeding from the surgical site. Post-tonsillectomy hemorrhage is a serious complication that requires immediate intervention.
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Related Questions
Correct Answer is A
Explanation
A. Pulmonary tuberculosis. This is correct because tuberculosis is a highly contagious airborne disease that must be reported to the health department for tracking, treatment, and public health intervention.
B. Fibromyalgia syndrome. This is incorrect because fibromyalgia is a chronic pain condition that is not infectious and does not require mandatory reporting.
C. Herpes simplex virus. This is incorrect because herpes simplex, though contagious, is not a reportable disease.
D. Methicillin-resistant Staphylococcus aureus. This is incorrect because MRSA infections are not universally required to be reported, though some states may have specific regulations for outbreaks in healthcare settings.
Correct Answer is A
Explanation
A. The nurse should complete an incident report and forward it to the risk manager within 24 hours as part of the facility’s protocol for reporting medication errors. This helps track errors, improve safety measures, and prevent future occurrences.
B. While a pharmacist may need to be involved in evaluating the error, there is no requirement to notify them within a specific timeframe. The priority is proper reporting and client monitoring.
C. Calling the nurse who made the error is not an appropriate action. Incident reports focus on improving systems rather than blaming individuals.
D. An incident report is not part of the medical record. It is an internal document used for quality improvement and risk management.
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