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. The Patient Self-Determination Act (PSDA) requires health care facilities to ask clients about advance directives upon admission and document their status in the medical record. This ensures that the client’s treatment preferences are known and respected.
B. Ensuring the client has an attorney is not a requirement of the PSDA. Clients may choose legal assistance, but it is not mandated by the act.
C. Providing end-of-life education is beneficial but not specifically required by the PSDA. The act focuses on informing clients of their rights regarding advance directives.
D. The PSDA does not require facilities to provide a list of eligible health care proxies. Instead, it ensures clients are informed of their right to appoint one.
Correct Answer is D
Explanation
A. Strain the client's urine. This is incorrect because straining urine is necessary for clients with radioactive seeds placed in the bladder, but not for prostate cancer brachytherapy, where the seeds typically remain in place.
B. Limit each of the client's visitors to 2 hr per day. This is incorrect because visitors should be limited to short durations, but the exact time is typically restricted to 30 minutes per visit rather than a total of 2 hours per day.
C. Attach a dosimeter to the client's gown. This is incorrect because a dosimeter should be worn by healthcare staff, not attached to the client. It helps monitor radiation exposure for staff members.
D. Instruct visitors to stay 1 m (3.3 feet) away from the client. This is correct because maintaining a safe distance from the client helps minimize radiation exposure for visitors. Visitors should also limit their time near the client and avoid close contact.
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