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. Initiating seclusion protocol should only be done in situations where the safety of the client or others is at risk and after appropriate assessment and intervention.
B. Correct. Acknowledging the client's emotions and showing empathy can help defuse the situation and promote effective communication.
C. Incorrect. Using personal protective equipment (face shield with mask) is not necessary when interacting with an agitated client unless there is a specific infection control concern.
D. Incorrect. Engaging the panic alarm is not necessary in this situation, as it may escalate the client's agitation.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"E"}
Explanation
Upper gastrointestinal (GI) endoscopy: This procedure is often indicated for patients presenting with symptoms suggestive of gastrointestinal bleeding, such as dark, tarry stools (melena), which can indicate bleeding in the upper GI tract.
Dark tarry stool: This finding suggests the presence of digested blood, which typically originates from the upper GI tract. This symptom, along with a history of abdominal pain that worsens after eating, indicates a potential peptic ulcer or other upper GI pathology.
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