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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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Incorrect. Documenting the client's understanding of adverse effects is important, but ensuring the client's knowledge about diaphragm use is the first step.

B. Incorrect. Teaching the client how to insert the diaphragm can be an important step, but first, it's essential to assess the client's existing knowledge.

C. Correct. Before proceeding with teaching or other actions, it's important to determine the client's baseline understanding of diaphragm use.

D. Incorrect. Supervising the return demonstration is important but should come after the client's knowledge level is assessed.

A. The client's heart rate increases by 10/min. B. The client's diastolic blood pressure increases by 10 mm Hg. C. The client reports heart palpitations. D. The client's systolic blood pressure decreases by 25 mm Hg.

Correct Answer is D

Explanation

Choice A rationale:

An increase in heart rate by 10 beats per minute when moving from a supine to a sitting position is a normal physiological response to compensate for decreased venous return and maintain cardiac output. This response does not indicate orthostatic hypotension.

Choice B rationale:

An increase in diastolic blood pressure by 10 mm Hg when moving from a supine to a sitting position is a normal response to compensate for the effects of gravity on blood flow. It helps maintain perfusion to vital organs and does not indicate orthostatic hypotension.

Choice C rationale:

Heart palpitations can occur due to various reasons, including anxiety or arrhythmias, but they are not specific signs of orthostatic hypotension. This symptom alone does not confirm the presence of orthostatic hypotension.

Choice D rationale:

A decrease in systolic blood pressure by 25 mm Hg or more when moving from a supine to a sitting position indicates orthostatic hypotension. Orthostatic hypotension is defined as a drop in systolic blood pressure of 20 mm Hg or more or a drop in diastolic blood pressure of 10 mm Hg or more within 3 minutes of standing up. This condition can cause dizziness, lightheadedness, or fainting and can be a side effect of antihypertensive medications or other underlying medical conditions.

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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

A nurse is caring for a female client who requests a contraceptive diaphragm. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is caring for a client who is taking antihypertensive medication and is moving from a supine to a sitting position.Which of the following findings should indicate to the nurse that the client is experiencing orthostatic hypotension?

Correct Answer is D

Explanation

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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?