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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Cantaloupe: Cantaloupe is considered high in potassium, with about 430 mg of potassium per cup. This makes it unsuitable for a client needing a low-potassium diet, as it can significantly contribute to elevated potassium levels.
B. Sweet potato: Sweet potatoes are very high in potassium, containing around 540 mg of potassium per half-cup serving. They are not recommended for individuals trying to manage or lower their potassium intake.
C. Orange juice: Orange juice provides approximately 500 mg of potassium per 1-cup serving. It is commonly avoided or limited in potassium-restricted diets due to its significant contribution to total potassium intake.
D. Wheat bread: Wheat bread contains a relatively low amount of potassium, about 60 to 70 mg per slice. Compared to the other options listed, wheat bread is much lower in potassium and is a better choice for clients who need to restrict potassium in their diet.
Correct Answer is B
Explanation
A. Temperature of 37.2° C (99.0° F): A temperature of 37.2° C is within the normal range and does not necessarily indicate infection. Mild temperature elevations are common in the immediate postoperative period due to inflammatory responses rather than infection, which typically presents with more significant fever.
B. Elevated WBC count: An elevated white blood cell (WBC) count is a classic and early indicator of infection. It reflects the body's immune response to a bacterial or viral invasion, and postoperative infections often present with leukocytosis, making it a key finding to monitor closely.
C. Pain rating of 4 on a scale of 0 to 10: Moderate pain is expected after surgery and does not, by itself, suggest infection. Postoperative pain should be assessed in context with other symptoms like redness, swelling, or drainage; pain alone, especially if stable, is not definitive for infection.
D. Increased urinary output: Increased urinary output is generally a positive sign of good kidney perfusion and hydration status. A decrease, not an increase, in urinary output would be more concerning postoperatively and could suggest complications, but not necessarily infection.
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