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 D
Explanation
As explained, holding the bottle directly over the sterile field can result in contamination. It's crucial to pour the solution from above or to the side of the sterile field, making sure the bottle doesn't touch the field or anything in the field. This minimizes the risk of contaminating the sterile setup.
If solution is spilled on the sterile field, that area is contaminated, and you cannot make it sterile again by covering it with gauze. The correct approach would be to discard the contaminated items and set up a new sterile field.
While it's important not to touch the label side of the bottle, this option doesn't address the action of placing the cap. The most important part of pouring a sterile solution is ensuring the cap stays sterile, which is what option D addresses.
When performing a sterile procedure, after removing the cap from a sterile bottle, the cap should be placed sterile-side up on a clean surface or a sterile field. This is because the sterile side of the cap should not touch any non-sterile surfaces, and placing it sterile-side up ensures it stays sterile.
Correct Answer is D
Explanation
A. A butterfly needle is not typically used for accessing implanted ports.
B. An angiocatheter is not typically used for accessing implanted ports.
C. A 25-gauge needle might be too small for accessing an implanted port.
D. Correct. A noncoring needle (Huber needle) is specifically designed for accessing implanted venous access ports to minimize damage to the port septum and prevent leakage.
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