A nurse is assessing a preschool-age child who is in the immediate postoperative period following a tonsillectomy. Which of the following assessment findings is the priority?

The child's throat pain increases.

The child refuses clear liquids.

The child cries often.

The child swallows frequently.

Answer and Explanation

The Correct Answer is D

Rationale:
A.   The child's throat pain is expected post-tonsillectomy and can be managed using analgesics or an ice collar. However, this is not a priority finding compared to frequent swallowing which may indicate bleeding which is a life-threatening complication of tonsillectomy.
B.   Refusing clear liquids may indicate discomfort but is not as urgent as a potential increase in throat pain.
C.   Crying often may be a response to discomfort but does not necessarily indicate a complication requiring immediate intervention.
D.   This assessment finding indicates that the child might have bleeding in the throat, which is a life-threatening complication of tonsillectomy. The nurse should

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Correct Answer is C

Explanation

Rationale:
A. Checking the newborn's eyes every 8 hours is not necessary for the management of hyperbilirubinemia or phototherapy.
B. Placing mittens on the newborn's hands is unrelated to the management of hyperbilirubinemia or phototherapy.
C. Monitoring the newborn's temperature every 2 hours is essential during phototherapy because infants are at risk of hypothermia due to increased heat loss from the lights.
D. Applying lotion to the newborn's skin is not recommended during phototherapy as it can interfere with the effectiveness of the lights.

A. Partial thromboplastin time (PTT) B. C-reactive protein (CRP) C. Erythrocyte sedimentation rate (ESR) D. Antistreptolysin O (ASO) titer E. Blood urea nitrogen (BUN)

Correct Answer is ["B","C","D"]

Explanation

A. Partial thromboplastin time (PTT) is not typically used in the diagnosis of rheumatic fever.
B. C-reactive protein (CRP) is elevated in cases of inflammation and can help confirm the diagnosis of rheumatic fever.
C. Erythrocyte sedimentation rate (ESR) is another marker of inflammation that can be elevated in rheumatic fever.
D. Antistreptolysin O (ASO) titer measures antibodies against streptolysin O produced by Group A Streptococcus, which can indicate recent streptococcal infection, contributing to the diagnosis of rheumatic fever.
E. Blood urea nitrogen (BUN) is not directly related to the diagnosis of rheumatic fever.

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A nurse is assessing a preschool-age child who is in the immediate postoperative period following a tonsillectomy. Which of the following assessment findings is the priority?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a 1-week-old newborn who has hyperbilirubinemia and is being treated with phototherapy. Which of the following actions should the nurse take?

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Correct Answer is ["B","C","D"]

Explanation

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