A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings should the nurse identify as the priority?

Sore throat

Dark brown emesis

Blood-tinged mucus

Frequent swallowing

Answer and Explanation

The Correct Answer is D

A. Sore throat. This is incorrect because a sore throat is an expected postoperative finding following a tonsillectomy and does not indicate a complication.
B. Dark brown emesis. This is incorrect because dark brown emesis may be swallowed blood from surgery and is not necessarily an immediate concern unless it continues or turns bright red.
C. Blood-tinged mucus. This is incorrect because small amounts of blood-tinged mucus are normal after a tonsillectomy and do not indicate active bleeding.
D. Frequent swallowing. This is correct because frequent swallowing can indicate active bleeding from the surgical site. Post-tonsillectomy hemorrhage is a serious complication that requires immediate intervention.

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Correct Answer is A

Explanation

A. Minimizing distractions helps children with ADHD focus better and improves concentration.
B. Writing by hand does not necessarily enhance concentration and may actually increase frustration for some children with ADHD.
C. A structured and predictable routine is beneficial for children with ADHD, so varying activities daily may be counterproductive.
D. Encouraging a child to read during an outdoor activity period may limit needed physical movement, which can help manage ADHD symptoms.

A. A client who had dialysis and is using an arteriovenous shunt in the left lower forearm B. A client who had a right hemisphere stroke C. A client who has a right peripherally inserted central catheter D. A client who had blood drawn from the right antecubital area 1 hr ago

Correct Answer is C

Explanation

A. A client who had dialysis and is using an arteriovenous shunt in the left lower forearm. This is incorrect because the arteriovenous shunt is in the lower forearm, not the upper arm where blood pressure is measured. The right arm can still be used.
B. A client who had a right hemisphere stroke. This is incorrect because a stroke does not necessarily contraindicate blood pressure measurement on the affected side unless there are complications such as edema or weakness.
C. A client who has a right peripherally inserted central catheter. This is correct because taking a blood pressure on the same side as a peripherally inserted central catheter (PICC) can cause pressure that may damage the catheter or affect its function. The left arm should be used instead.
D. A client who had blood drawn from the right antecubital area 1 hr ago. This is incorrect because drawing blood from an arm does not contraindicate blood pressure measurement in that arm after a short period.

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A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings should the nurse identify as the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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