A nurse is closely monitoring a pediatric client following a tonsillectomy. Which finding would alert the nurse to a postoperative complication?
Dry mouth
Reports of mild to moderate pain
Dried flecks of blood in oral secretions
Frequent swallowing
The Correct Answer is D
A. Dry mouth is expected postoperatively, especially if the child is not drinking adequate fluids, but it is not a sign of a complication.
B. Mild to moderate pain is expected after a tonsillectomy and should be managed with analgesics.
C. Dried flecks of blood in oral secretions can be normal immediately after surgery, but active bleeding would be concerning.
D. Frequent swallowing is a sign of possible postoperative bleeding, which is a serious complication that requires immediate evaluation and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. Droplet precautions are typically used for infections transmitted through respiratory droplets, such as influenza or COVID-19. Since the symptoms described are more consistent with pyloric stenosis rather than an infectious disease, droplet precautions are not indicated.
B. The infant's symptoms are indicative of possible hypertrophic pyloric stenosis, a condition where the pylorus (the opening from the stomach to the small intestine) becomes narrowed, leading to forceful vomiting and dehydration. Surgical intervention, such as a pyloromyotomy, is often required to correct this condition.
C. The FLACC (Face, Legs, Activity, Cry, Consolability) scale is used to assess pain in infants and young children who cannot verbalize their discomfort. Given the infant's fussiness and symptoms, evaluating pain is crucial to managing the infant's discomfort.
D. Monitoring intake and output is important in an infant with vomiting to assess for dehydration and ensure appropriate fluid balance. This is a key aspect of managing any vomiting-related condition and ensuring the infant receives adequate hydration.
E. In the case of hypertrophic pyloric stenosis, thickened liquids are not recommended. The main treatment is surgical, and feeding modifications alone will not address the underlying condition.
F. A plain water enema is not appropriate for this infant’s symptoms. Hypertrophic pyloric stenosis does not require an enema and may actually worsen the infant's condition.
Correct Answer is B
Explanation
A. Intravenous fluids are generally not required if the child is alert and active with mild dehydration; oral rehydration is usually sufficient.
B. Oral rehydration solutions are appropriate for treating mild dehydration and should be given in small amounts frequently.
C. Chicken broth is not ideal for replacing electrolytes because it is low in electrolytes and high in sodium. Oral rehydration solutions are preferred.
D. A depressed soft spot (fontanel) is a sign of severe dehydration in infants. For a 4-year-old, signs of dehydration would include changes in urine output, thirst, or dry mucous membranes rather than a depressed fontanel.
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