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 ["A","C","D"]

Explanation

A. Correct. Reinforcing orientation to time, place, and person helps ground the client in reality, even if their memory is impaired.

B. Incorrect. While it's important to provide the client with some choices, too many options can be overwhelming and confusing.

C. Correct. Providing one simple direction at a time helps prevent confusion and frustration for clients with dementia.

D. Correct. Establishing eye contact while communicating can enhance the client's focus and understanding.

E. Incorrect. It's generally not effective to try to refute a client's delusions using logic.

Redirecting or validating their feelings might be more appropriate.

A. Clean the equipment with an alcohol-based cleaning product. B. Apply petroleum jelly to soothe the mucous membranes. C. Use synthetic fabrics for the client's bedding. D. Avoid using nail polish remover around the client.

Correct Answer is D

Explanation

A. Alcohol-based cleaning products are flammable and should not be used near oxygen equipment.
B. Petroleum jelly is also flammable and should not be applied to the client's face when using oxygen therapy.
C. Synthetic fabrics cangenerate static electricity, which could potentially lead to a fire hazard in the presence of oxygen.
D. Nail polish remover is flammable and should be avoided near oxygen equipment.

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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?