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. 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.
Correct Answer is A
Explanation
A. Discontinue use of electronics 30 min before bedtime: The use of electronics before bedtime can disrupt the body's natural sleep cycle by suppressing melatonin production. Stopping electronic use at least 30 minutes before bed promotes relaxation and better sleep quality.
B. Drink a cup of coffee 1 hr before bedtime: Caffeine is a stimulant that can interfere with falling asleep and maintaining deep sleep. Consuming coffee close to bedtime would likely worsen sleep disturbances rather than help.
C. Consume a meal 1 hr before bedtime: Eating a large meal close to bedtime can cause discomfort, indigestion, and difficulty falling asleep. Light snacks are acceptable, but heavy meals should be avoided before sleeping.
D. Exercise 1 hr before bedtime: Vigorous exercise shortly before bedtime can increase adrenaline and body temperature, making it harder to fall asleep. Exercise is better scheduled earlier in the day to support restful sleep.
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