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

Answer and Explanation

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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Correct Answer is D

Explanation

A. Insomnia: While insomnia can be a side effect of sertraline, it is not typically associated with serotonin syndrome. However, if the insomnia is severe or accompanied by other symptoms of serotonin syndrome, it should be reported to the healthcare provider.
B. Constipation: Constipation is a common side effect of sertraline but is not indicative of serotonin syndrome. It is important to monitor for constipation and manage it appropriately but not as an indicator of serotonin syndrome.
C. Dry mouth: Dry mouth is another common side effect of sertraline but is not specific to serotonin syndrome. While uncomfortable, it does not typically require immediate reporting unless severe or accompanied by other concerning symptoms.
D. Excessive sweating: Excessive sweating, also known as diaphoresis, is a hallmark symptom of serotonin syndrome. It is a significant indicator of serotonin toxicity and should be reported immediately to the healthcare provider for further evaluation and management.

A. Wire cutters B. Montgomery straps C. Tracheostomy tray D. Padded clamp

Correct Answer is D

Explanation

A. Wire cutters:
Wire cutters are typically not necessary for postoperative care following a thoracotomy with chest tube placement. They are more commonly used in situations such as removing orthopedic hardware or cutting wires in emergency situations. Therefore, wire cutters are not essential equipment for this particular procedure.

B. Montgomery straps:
Montgomery straps are adhesive strips used to secure dressings or bandages without the need for tape. While they can be useful in some postoperative situations, they are not specifically required for a thoracotomy with chest tube placement.

C. Tracheostomy tray:

A tracheostomy tray contains equipment necessary for performing tracheostomy care, such as sterile gloves, tracheostomy tubes, and suctioning equipment. It is not directly related to thoracotomy or chest tube care post op.

D. Padded clamp:
A padded clamp, or chest tube holder, is a device used to secure chest tubes in place and prevent them from being accidentally dislodged. It is an essential piece of equipment for postoperative care following a thoracotomy with chest tube placement, as it helps maintain the integrity of the chest tubes and prevents complications such as air leaks or pneumothorax.

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A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings should the nurse identify as the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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