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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
To calculate how many tablets of levothyroxine the nurse should administer, we'll need to convert the dose to the same unit as the available tablets. Here's the step-by-step process:
Convert the desired dose to milligrams (mg): 50 micrograms (mcg) = 50 / 1000 mg (since 1 mg = 1000 mcg) 50 mcg = 0.05 mg
Now, find out how many tablets of 0.025 mg each are required to achieve the desired dose: Number of tablets = Desired dose (in mg) / Tablet strength (in mg) Number of tablets = 0.05 mg / 0.025 mg Number of tablets = 2 tablets
Therefore, the nurse should administer 2 tablets per dose.
Correct Answer is D
Explanation
A. Incorrect. Encouraging the client to lie down in a quiet room is not specifically related to addressing auditory hallucinations.
B. Incorrect. Referring to hallucinations as if they are real can reinforce the client's delusions or hallucinations.
C. Incorrect. Avoiding eye contact can be perceived as dismissive or uninterested.
D. Correct. Asking the client directly about their hallucinations helps assess their content and severity, which is essential for developing an effective plan of care.
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