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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Drink high-protein nutritional supplements between meals: Clients with COPD often experience anorexia due to fatigue, difficulty breathing while eating, and early satiety. High-protein, high-calorie supplements between meals help meet nutritional needs without overwhelming them during main meals, supporting energy levels and respiratory muscle strength.
B. Eat more hot foods than cold foods at mealtime: Hot foods can produce stronger odors that may worsen appetite loss. Cold foods tend to have milder smells and may be better tolerated by clients with anorexia, making cold foods preferable rather than focusing on hot foods.
C. Eat low-calorie foods first at mealtime: Clients with anorexia and COPD should prioritize high-calorie, nutrient-dense foods first to maximize intake before feeling full. Eating low-calorie foods first could reduce overall calorie intake, worsening weight loss and malnutrition risks.
D. Increase liquids during meals: Consuming large amounts of liquid during meals can cause early satiety, making it harder for clients to consume enough food. It is better to encourage drinking fluids between meals to optimize food intake during eating times.
Correct Answer is A
Explanation
A. Reviewing the results of the client's chlamydia screening with their parents, without the client's consent: Sexual health information, including STI screenings, is protected by confidentiality laws even for minors in many regions. Disclosing such sensitive information without the client's consent breaches confidentiality and can undermine trust between the adolescent and healthcare providers.
B. Reviewing the results of the client's celiac screening with their parents, without the client's consent: Celiac screening relates to general medical conditions and nutritional health, which are typically shared with parents of minors unless otherwise restricted. This does not generally breach confidentiality because it is not considered sensitive under adolescent health privacy laws.
C. Reviewing the results of the client's complete blood count (CBC) with their parents, without the client's consent: A CBC is a routine diagnostic test that checks general health indicators such as anemia or infection. Discussing these results with parents, especially for minors, is standard practice and does not usually violate confidentiality.
D. Reviewing the results of the client's urinalysis with their parents, without the client's consent: Urinalysis results typically assess general health or identify infections, which are standard to share with parents in the care of minors. This action would not be considered as a breach of confidentiality unless it revealed sensitive information like substance use without consent.
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