A nurse is collecting data from a child who is 1 hr postoperative following a tonsillectomy. Which of the following findings is the nurse's priority?

Frequent swallowing

Report of sore throat

Dark brown blood between the teeth

Coffee-ground appearance of emesis

Answer and Explanation

The Correct Answer is A

A. Frequent swallowing: Frequent swallowing after a tonsillectomy can be a sign of active bleeding from the surgical site. Even if bleeding is not visible, the child may be swallowing blood, which can lead to significant hemorrhage. This is the priority finding that requires immediate intervention.

B. Report of sore throat: A sore throat is an expected and normal finding after a tonsillectomy due to surgical trauma and healing. It does not represent an urgent or life-threatening complication.

C. Dark brown blood between the teeth: Dark brown blood suggests old, minimal bleeding and is not as concerning as active bright red bleeding. While it should be monitored, it is not the priority compared to signs of active hemorrhage.

D. Coffee-ground appearance of emesis: Coffee-ground emesis suggests the presence of digested blood, often from swallowed blood, and while concerning, it is a secondary finding. Frequent swallowing points more directly to active bleeding, which is more immediately life-threatening.

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Correct Answer is C

Explanation

A. The client tells the nurse he prefers a snack before bedtime: Client food preferences can usually be accommodated by nursing and dietary staff without needing interprofessional team intervention unless related to special dietary restrictions.

B. The client requires reinforcement of teaching about the purpose of his medications: Medication education reinforcement is a routine nursing responsibility and typically does not require escalation to the entire interprofessional team unless there are significant comprehension issues.

C. The client is unable to grasp eating utensils: Difficulty grasping utensils suggests significant motor deficits following the stroke. This functional limitation requires input from occupational therapy, physical therapy, and possibly speech therapy to assess needs for adaptive devices and rehabilitation strategies.

D. The client requests to perform ADLs later in the day: Adjusting the timing of ADLs is a minor scheduling preference and does not necessarily require interprofessional reporting unless it impacts therapy schedules or rehabilitation goals.

A. Blood pressure B. Platelet count C. Alanine aminotransferase (ALT) D. Hemoglobin

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A"}}

Explanation

Blood pressure: The client's significantly elevated blood pressure (162/112 mm Hg and 166/110 mm Hg) is characteristic of preeclampsia, which is defined by new-onset hypertension after 20 weeks of gestation. Hypertension is a major diagnostic criterion for preeclampsia but is not required for diagnosing HELLP syndrome.
Platelet count: The platelet count of 98,000/mm³ is lower than normal, supporting both preeclampsia and HELLP syndrome. In preeclampsia, thrombocytopenia can occur as the disease progresses, and in HELLP syndrome, low platelets are one of the triad components (Hemolysis, Elevated Liver enzymes, Low Platelet count).
Alanine aminotransferase (ALT): An ALT level of 40 Units/L is above the normal limit, indicating liver involvement. Elevated liver enzymes occur in both severe preeclampsia and HELLP syndrome, reflecting hepatic dysfunction or injury caused by systemic endothelial damage.
Hemoglobin: A hemoglobin of 18.0 g/dL is unusually high and suggests hemoconcentration, which is typical of preeclampsia due to fluid shifts out of the vascular space. In contrast, HELLP syndrome typically causes hemolysis leading to anemia, where hemoglobin would be expected to be low rather than elevated.

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A nurse is assisting with the care of a client.

Select the 4 responsibilities the nurse has in relation to the client's advance directives.

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Area assessed	Findings
Neurological	Drowsy but easy to arouse
Vital Signs	Temperature 35.3°C (95.5° F) Heart rate 60/min Respiratory rate 16/min Blood pressure 90/60 mm Hg Oxygen saturation 94% (oxygen at 2 L/min via nasal cannula) Rates pain as 1 on 0/10 pain scale.
Integumentary	Skin cool and moist to touch.
Cardiopulmonary	Heart rate regular. Pedal pulse +1 bilateral. Lungs clear bilateral. Respirations even, nonlabored.
Abdomen	Abdomen soft, nondistended. Bowel sounds hypoactive in all four quadrants. 2x2 gauze with a clear transparent dressing intact to right lower and upper abdominal quadrant. Moderate amount of sanguineous drainage noted on the lower dressing

A nurse is collecting data from a child who is 1 hr postoperative following a tonsillectomy. Which of the following findings is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is participating in an interprofessional client care conference for a client who has experienced a stroke. The nurse should identify that which of the following client care issues requires reporting to the interprofessional team?

Correct Answer is C

Explanation

The nurse is reviewing the findings. For each finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A"}}

Explanation

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