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.

Frequent swallowing.

Blood-tinged mucus.

Dark brown emesis.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

A sore throat is a common and expected finding after a tonsillectomy due to irritation from the procedure. While it can cause discomfort, it is not a priority concern unless it worsens significantly or is accompanied by other symptoms indicating complications such as bleeding or infection.

Choice B rationale:

Frequent swallowing can be a sign of bleeding after a tonsillectomy. The child may swallow more often to clear blood or blood clots from the throat, which could indicate that there is active bleeding from the surgical site.

Choice C rationale:

Blood-tinged mucus is a common finding in the immediate postoperative period after a tonsillectomy. It is expected due to the healing process and is not a cause for concern unless it becomes profuse or is accompanied by active bleeding.

Choice D rationale:

While dark brown vomit may indicate that the child has swallowed blood, it is not as immediately concerning as frequent swallowing, which could suggest active bleeding at the surgical site. Dark brown emesis is typically less alarming, but it should still be monitored closely.

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Correct Answer is D

Explanation

A. The balloon port is used to inflate or deflate the catheter balloon and is not used for obtaining urine specimens.
B. Unclamping the collection port could contaminate the specimen with non-sterile urine from the tubing.
C. Disconnecting the catheter from the collection tubing could introduce contaminants into the catheter and tubing.
D. Correct. The retention port is a sterile access point on the catheter itself, and it can be used to obtain a sterile urine specimen without compromising the sterility of the collection system.

A. Offer small amounts of clear liquids 6 hr following surgery. B. Give cromolyn nebulized solution every 8 hr. C. Apply a warm compress to the operative site once daily. D. Administer analgesics on a scheduled basis for the first 24 hr.

Correct Answer is D

Explanation

A. Incorrect. Clear liquids are usually introduced slowly and progressively, but 6 hours postoperative might be too soon for this intervention.

B. Incorrect. Cromolyn nebulized solution is used to prevent asthma symptoms triggered by certain factors, not for postoperative care.

C. Incorrect. Applying a warm compress to the operative site might not be appropriate for the immediate postoperative period, especially in the case of appendicitis.

D. Correct. Administering analgesics on a scheduled basis helps manage postoperative pain and provides effective pain relief, promoting comfort and recovery.

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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?

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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?