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. A child with cystic fibrosis and difficulty clearing secretions is the priority because airway clearance is critical in cystic fibrosis. Mucus buildup can lead to respiratory distress and infection, requiring immediate intervention.
B. A child with an atrial septal defect and a heart rate of 120/min is not the priority because a heart rate of 120/min is within the expected range for a 3-year-old and does not indicate immediate distress.
C. A child with type 1 diabetes and a blood sugar of 150 mg/dL is not the priority because this blood glucose level is slightly elevated but not critical.
D. A child with diarrhea and abdominal pain requires assessment, but dehydration or electrolyte imbalance develops over time. Airway issues take priority over gastrointestinal symptoms.
Correct Answer is B
Explanation
A. Simply documenting the client's lack of understanding does not address their immediate need for clarification. The nurse must take action.
B. The provider is responsible for obtaining informed consent and ensuring the client understands the procedure. The nurse should notify the provider so they can provide the necessary explanation.
C. Discussing other treatment options is beyond the nurse’s scope of practice. Only the provider should discuss alternative treatments.
D. The nurse can reinforce teaching but cannot provide new information about the surgery. Since the client is unsure about the procedure, the provider must explain it.
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