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
A. Incorrect. Leaving a nasogastric tube clamped after administering oral medication is a mistake, but it may not necessarily be considered malpractice if it doesn't result in harm or negligence.
B. Incorrect. Placing a yellow bracelet on a client at risk for falls is a safety measure, and it's not an example of malpractice.
C. Correct. Administering potassium via IV bolus can be dangerous and is considered malpractice if not done properly. Rapid administration of potassium via IV bolus can lead to serious cardiac complications.
D. Incorrect. Documenting communication with a provider in the progress notes of the client's medical record is a standard practice and not an example of malpractice.
Correct Answer is A
Explanation
A. Correct. Having regular interdisciplinary team meetings allows healthcare professionals from various disciplines to collaborate, share information, and ensure coordinated care for the client with complex needs.
B. Noting changes in the treatment plan in the client's medical record is important, but it may not directly promote effective communication among staff.
C. Recording the client's progress in the nurses' notes is essential but may not address the need for communication among the entire care team.
D. Posting swallowing precautions at the head of the client's bed is important for the client's safety but does not directly address communication among staff members.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.