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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Shake both insulin vials for 2 min before withdrawing the doses. Insulin vials should never be shaken, as this can create air bubbles and affect dosage accuracy. NPH insulin should be gently rolled between the hands to mix.
B. Administer the mixture within 5 min of preparing it. While insulin should be administered promptly, there is no strict 5-minute requirement.
C. Withdraw the NPH insulin before the regular insulin. Regular insulin should be drawn up first to prevent contamination with the cloudy NPH insulin.
D. Inject air into the regular insulin vial before injecting air into the NPH vial. Air should be injected into the regular insulin first, then into the NPH insulin vial, before withdrawing the doses in the correct order.
Correct Answer is A
Explanation
A. Keeping the umbilical cord area clean and dry helps prevent infection. Washing the base of the cord with water is recommended, while avoiding full immersion in water until the cord falls off.
B. The diaper should be folded down below the cord to prevent moisture buildup and irritation. Covering it can trap moisture and increase the risk of infection.
C. Minor bleeding is not expected when the stump falls off. Persistent or excessive bleeding should be reported to the provider.
D. Petroleum jelly is not recommended for umbilical cord care. The cord should be kept dry to facilitate natural detachment.
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