A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings is a manifestation of hemorrhage?
Drooling
Poor fluid intake
Increased pain
Frequent swallowing
The Correct Answer is D
Choice A reason: Drooling is not a sign of hemorrhage, but rather a sign of difficulty swallowing or breathing. Drooling may occur after a tonsillectomy due to throat pain or swelling, but it does not indicate bleeding.
Choice B reason: Poor fluid intake is not a sign of hemorrhage, but rather a sign of dehydration or nausea. Poor fluid intake may occur after a tonsillectomy due to throat pain or fear of swallowing, but it does not indicate bleeding.
Choice C reason: Increased pain is not a sign of hemorrhage, but rather a sign of inflammation or infection. Increased pain may occur after a tonsillectomy due to tissue damage or healing, but it does not indicate bleeding.
Choice D reason: Frequent swallowing is a sign of hemorrhage, as it indicates that the child is trying to clear blood from the throat. Frequent swallowing may occur after a tonsillectomy due to bleeding from the surgical site or a ruptured blood vessel.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the best option to prevent the toddler from touching or injuring the surgical site. The nurse should apply soft padded restraints and check the circulation and skin integrity of the wrists frequently.
Choice B reason: Offering fluids through a straw is not recommended for a toddler who has had a cleft palate repair, as it can cause suction and pressure in the mouth that can disrupt the sutures. The nurse should offer fluids with a cup or a spoon.
Choice C reason: Implementing a soft diet is not appropriate for a toddler who has had a cleft palate repair, as it can cause irritation and infection in the mouth. The nurse should provide clear liquids for the first 24 hr and then advance to full liquids as tolerated.
Choice D reason: Administering opioids for pain is not the first choice for a toddler who has had a cleft palate repair, as it can cause respiratory depression and constipation. The nurse should use nonpharmacological methods such as distraction, comfort, and reassurance first, and then administer acetaminophen or ibuprofen as prescribed.
Correct Answer is D
Explanation
Choice A reason: This statement is incorrect, as the child should take the enzymes before or with meals, not after. Taking the enzymes after meals may reduce their effectiveness and cause malabsorption of nutrients.
Choice B reason: This statement is incorrect, as the child should take the enzymes within 30 minutes before meals, not 2 hours. Taking the enzymes too early may cause them to be inactivated by the stomach acid and lose their function.
Choice C reason: This statement is incorrect, as the child does not take the enzymes to improve her metabolism, but to replace the deficient pancreatic enzymes that are needed for digestion. The child has cystic fibrosis, a genetic disorder that affects the exocrine glands and causes thick mucus to block the ducts of the pancreas.
Choice D reason: This statement is correct, as the child takes the enzymes to help digest the fat in foods, as well as other nutrients such as protein and carbohydrates. The enzymes contain lipase, amylase, and protease, which break down fat, starch, and protein respectively.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today