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. While staff training is important, it may not address the immediate concern of identifying the cause of the infections.
B. Correct. Identifying the possible factors contributing to the infections is the first step in addressing the issue and preventing further infections.
C. Meeting with providers can be beneficial, but identifying the cause should come first before discussing measures.
D. Revising the policy for catheter care can be considered once the contributing factors are identified.
Correct Answer is D
Explanation
Digoxin is a medicine used to treat various heart conditions, including heart failure and irregular heartbeat1. It is important to follow the doctor’s instructions carefully when giving digoxin to your child, as the dosage and timing may vary depending on your child’s age, weight, and medical condition.
Out of the four statements you provided, only one is correct. The correct statement is:
d. “Have your child drink a small glass of water after swallowing the medication.”
This statement is correct because drinking water after taking digoxin can help prevent stomach upset and ensure proper absorption of the medicine.
The other three statements are incorrect and should not be followed. Here are the reasons why:
a. “You can add the medication to a half-cup of your child’s favorite juice.”
This statement is incorrect because adding digoxin to juice or other liquids can alter the concentration and effectiveness of the medicine4. You should give digoxin to your child by mouth with or without food, using a marked measuring spoon or medicine cup. If you are using the liquid form of digoxin, you can give a small squirt of the medicine inside the cheek and let your child swallow it before giving more.
b. “Repeat the dose if your child vomits within 1 hour after taking the medication.”
This statement is incorrect because repeating the dose of digoxin can increase the risk of overdose and side effects4. Digoxin has a narrow therapeutic range, which means that too much or too little of the medicine can be harmful. If your child vomits within 1 hour after taking digoxin, do not give another dose and continue with the normal dose amount at the next scheduled time4. If your child vomits frequently or has signs of overdose, such as nausea, drowsiness, confusion, vision changes, or irregular heartbeat, call your doctor or poison control center immediately.
c. “Limit your child’s potassium intake while she is taking this medication.”
This statement is incorrect because limiting your child’s potassium intake can actually worsen the effects of digoxin6. Digoxin works by affecting the levels of sodium and potassium in the heart cells, which helps regulate the heart rhythm and contractility. However, low potassium levels can make digoxin more toxic and increase the risk of arrhythmias6. Therefore, you should not restrict your child’s potassium intake unless instructed by your doctor6. You should also avoid giving your child foods or supplements that are high in fiber, as they can interfere with the absorption of digoxin. Some examples of high-fiber foods are bran, psyllium, and some fruits and vegetables
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