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 B
Explanation
A. Incorrect. Absence seizures typically do not have an aura. They are characterized by a sudden and brief loss of awareness without warning.
B. Correct. Absence seizures often involve a brief period of staring and decreased responsiveness. They can indeed be mistaken for daydreaming, as they are not as dramatic as other types of seizures.
C. Incorrect. Absence seizures are usually very brief, lasting only a few seconds (often less than 10 seconds), rather than 30 to 60 seconds.
D. Incorrect. Absence seizures have a sudden and abrupt onset, not a gradual one. They occur without warning and without a preceding aura.
Correct Answer is A
Explanation
Choice A rationale:
A capillary glucose level of 198 mg/dL in a client receiving total parenteral nutrition (TPN) suggests hyperglycemia, which is a common complication of TPN. TPN solutions are high in glucose, and clients receiving TPN are at risk of developing hyperglycemia. Regular monitoring of blood glucose levels is necessary to detect and manage hyperglycemia promptly.
Choice B rationale:
Serum albumin level of 3.9 g/dL is within the normal range (3.5-5.5 g/dL) and does not indicate a complication of TPN. Low serum albumin levels could suggest malnutrition or liver disease, but in this case, the level is normal.
Choice C rationale:
Hemoglobin (Hgb) level of 15.6 g/dL is within the normal range for both men and women, indicating an adequate oxygen-carrying capacity of the blood. This result does not suggest a complication related to TPN.
Choice D rationale:
White blood cell (WBC) count of 7,000/mm³ is within the normal range (4,500-11,000/mm³) and does not indicate a complication of TPN. Elevated WBC count could suggest an infection, but in this case, the count is normal.
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