A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings should the nurse identify as the priority?
Frequent swallowing
Dark brown emesis
Sore throat
Blood-tinged mucus
The Correct Answer is A
Answer: A
Rationale:
A. Frequent swallowing: Frequent swallowing in a postoperative tonsillectomy patient can be a sign of bleeding or a hemorrhage. This is a priority finding because it may indicate that the child is swallowing blood, which requires immediate intervention to prevent significant blood loss and complications.
B. Dark brown emesis: Dark brown emesis can be a normal finding post-tonsillectomy, as it may indicate the presence of old blood or clotted blood. While it should be monitored, it is not as urgent as frequent swallowing, which may signify active bleeding.
C. Sore throat: A sore throat is a common postoperative symptom following a tonsillectomy and is generally expected. It is important to manage pain and discomfort, but it is not as urgent as signs of potential bleeding.
D. Blood-tinged mucus: Blood-tinged mucus can occur after a tonsillectomy due to irritation or minor bleeding. While it should be observed, it is less critical compared to frequent swallowing, which may indicate more significant bleeding.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Preeclampsia: Preeclampsia is not a contraindication for the administration of misoprostol for induction of labor. In some cases, it may even be indicated to prevent complications associated with continuing the pregnancy.
B. Transverse fetal lie: A transverse fetal lie, where the baby is positioned sideways in the uterus, is a contraindication for the administration of misoprostol for induction of labor. Misoprostol is contraindicated when the fetal presentation is not cephalic (head down) due to the risk of complications, including cord prolapse.
C. Post-term pregnancy: Misoprostol is commonly used for induction of labor in post-term pregnancies, where the pregnancy has extended beyond 42 weeks. It helps initiate uterine contractions to stimulate labor and reduce the risk of complications associated with prolonged gestation.
D. Intrauterine growth restriction: Intrauterine growth restriction is not a contraindication for the administration of misoprostol for induction of labor. In such cases, the decision to induce labor would depend on various factors related to fetal well-being and maternal health.
Correct Answer is C
Explanation
A. "Eat a high-fat snack at bedtime": Consuming high-fat foods, especially close to bedtime, can exacerbate heartburn symptoms. Fatty foods delay gastric emptying and can contribute to increased acid production, leading to heartburn. Therefore, advising the client to avoid high-fat snacks before bedtime is essential for managing heartburn.
B. "Sip carbonated beverages throughout the day": Carbonated beverages, including soda and sparkling water, can exacerbate heartburn symptoms due to their acidic nature and carbonation. Therefore, advising the client to avoid or limit carbonated beverages is essential for managing heartburn.
C. "Drink hot herbal tea to relieve symptoms": Herbal teas such as chamomile or ginger tea can help alleviate heartburn symptoms by promoting digestion and soothing the gastrointestinal tract. Warm beverages can have a soothing effect on the esophagus and stomach, potentially providing relief from heartburn discomfort. Therefore, advising the client to drink hot herbal tea to relieve symptoms is an appropriate recommendation.
D. "Lie down for 30 min after meals": Remaining upright for at least 30 minutes after meals can help prevent acid reflux and reduce the risk of heartburn. However, lying down immediately after eating can worsen heartburn symptoms by allowing stomach acid to flow back into the esophagus. Therefore, advising the client to lie down for 30 minutes after meals is not an appropriate instruction for managing heartburn.
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