A nurse is collecting data from a child who is 1 hr postoperative following a tonsillectomy. Which of the following findings is the nurse's priority?

Frequent swallowing

Report of sore throat

Dark brown blood between the teeth

Coffee-ground appearance of emesis

Answer and Explanation

The Correct Answer is A

A. Frequent swallowing: Frequent swallowing after a tonsillectomy can be a sign of active bleeding from the surgical site. Even if bleeding is not visible, the child may be swallowing blood, which can lead to significant hemorrhage. This is the priority finding that requires immediate intervention.

B. Report of sore throat: A sore throat is an expected and normal finding after a tonsillectomy due to surgical trauma and healing. It does not represent an urgent or life-threatening complication.

C. Dark brown blood between the teeth: Dark brown blood suggests old, minimal bleeding and is not as concerning as active bright red bleeding. While it should be monitored, it is not the priority compared to signs of active hemorrhage.

D. Coffee-ground appearance of emesis: Coffee-ground emesis suggests the presence of digested blood, often from swallowed blood, and while concerning, it is a secondary finding. Frequent swallowing points more directly to active bleeding, which is more immediately life-threatening.

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Correct Answer is D

Explanation

A. "You will receive moderate sedation prior to the procedure.": Moderate sedation is not typically required for a thoracentesis. Instead, local anesthesia is used at the puncture site to minimize discomfort. The client remains awake, able to follow instructions, and does not require the same level of monitoring associated with moderate sedation.

B. "You will need to lie on your affected side for 30 minutes following the procedure.": After a thoracentesis, clients are usually positioned on the unaffected side to allow the lung on the affected side to re-expand and to minimize the risk of complications such as pneumothorax. Lying on the affected side could worsen the client's condition post-procedure.

C. "You will not be able to eat or drink four hours prior to the procedure.": Thoracentesis is not a gastrointestinal or airway procedure that necessitates fasting beforehand. Clients are typically allowed to eat and drink normally unless another procedure requiring fasting is planned, as the risk of aspiration is minimal with thoracentesis.

D. "You will be placed leaning over a bedside table during the procedure.": Clients undergoing thoracentesis are positioned sitting upright, leaning slightly forward over a bedside table with pillows for support. This position helps spread the ribs apart and provides the best access to the pleural space while minimizing the risk of lung injury.

A. Place the client in a supine position B. Empty the collection chamber every 8 hr C. Ensure the device is kept below the level of the client's chest. D. Clamp the chest tube every 4hr

Correct Answer is C

Explanation

A. Place the client in a supine position: A supine position can impair lung expansion and increase the risk of respiratory complications. Clients with a chest tube are best positioned in a semi-Fowler’s or high-Fowler’s position to promote lung re-expansion and ease of breathing.

B. Empty the collection chamber every 8 hr: The collection chamber in a chest drainage system should not be emptied routinely, it should be emptied as needed to prevent it from overfilling. It is a closed system, and breaking it by emptying can introduce infection or disrupt the pressure needed for effective drainage.

C. Ensure the device is kept below the level of the client's chest: Keeping the chest drainage system below chest level uses gravity to promote drainage and prevents backflow of fluid or air into the pleural space. This positioning is essential to maintain the effectiveness and safety of the chest tube system.

D. Clamp the chest tube every 4 hr: Routine clamping of a chest tube is not recommended as it can lead to a dangerous buildup of air (tension pneumothorax). Clamping is reserved for specific, short-term procedures under direct provider orders, such as changing the drainage system.

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A nurse is collecting data from a child who is 1 hr postoperative following a tonsillectomy. Which of the following findings is the nurse's priority?

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