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.
Frequent swallowing.
Blood-tinged mucus.
Dark brown emesis.
The Correct Answer is B
Choice A rationale:
A sore throat is a common and expected finding after a tonsillectomy due to irritation from the procedure. While it can cause discomfort, it is not a priority concern unless it worsens significantly or is accompanied by other symptoms indicating complications such as bleeding or infection.
Choice B rationale:
Frequent swallowing can be a sign of bleeding after a tonsillectomy. The child may swallow more often to clear blood or blood clots from the throat, which could indicate that there is active bleeding from the surgical site.
Choice C rationale:
Blood-tinged mucus is a common finding in the immediate postoperative period after a tonsillectomy. It is expected due to the healing process and is not a cause for concern unless it becomes profuse or is accompanied by active bleeding.
Choice D rationale:
While dark brown vomit may indicate that the child has swallowed blood, it is not as immediately concerning as frequent swallowing, which could suggest active bleeding at the surgical site. Dark brown emesis is typically less alarming, but it should still be monitored closely.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Overweight is not applicable in this situation as the client's BMI indicates a weight status below the normal range.
Choice B rationale:
Obesity class 1 is not applicable in this situation as the client's BMI indicates a weight status below the normal range.
Choice C rationale:
Underweight is the correct choice. A BMI of less than 18.5 is considered underweight according to the World Health Organization (WHO) classification. A BMI of 17.2 falls below this threshold, indicating that the client is underweight. This is a cause for concern, as individuals with Crohn's disease often struggle with maintaining a healthy weight due to malabsorption issues and reduced appetite.
Choice D rationale:
Healthy weight is not applicable in this situation as the client's BMI is below the normal range, indicating an underweight status.
Correct Answer is C
Explanation
A. Incorrect. Temporarily discontinuing the TPN infusion may result in an abrupt decrease in the client's glucose intake, which could lead to hypoglycemia.
B. Incorrect. Giving lactated Ringer's solution would not address the client's TPN needs and may also affect electrolyte balance.
C. Administering dextrose 10% in water wouldprovide the required glucosed as the next bag is awaited
D. Slowing the TPN infusion rate can help stretch the remaining volume until a new bag becomes available. However, it does not adress the body's glucose requirements.
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