Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a school-age child who is postoperative following surgical removal of their tonsils. Which of the following manifestations should the nurse identify as a potential complication?
A. Continuous swallowing
Continuous swallowing is a key early sign of postoperative hemorrhage after tonsillectomy. Blood from the surgical site may trickle into the throat and be swallowed repeatedly, especially in children who cannot verbalize symptoms effectively. This behavior often precedes visible bleeding and requires immediate assessment and intervention.
B. Inflamed throat
Inflamed throat is an expected postoperative finding following tonsillectomy due to surgical tissue trauma. Mild to moderate throat inflammation, pain, and redness are normal during the healing process. This finding alone does not indicate a complication unless it is accompanied by signs of infection or bleeding.
C. impaired taste
Impaired taste is not a common or clinically significant complication following tonsillectomy. Temporary taste changes may occur due to swelling or discomfort, but they are not considered a warning sign of postoperative complications. This symptom is usually transient and resolves with healing.
D. Dark blood in emesis
Dark blood in emesis may indicate partially digested blood but is not as reliable or early a sign of hemorrhage as continuous swallowing. It can suggest bleeding, but it often appears after blood has accumulated in the stomach. Early detection is more effectively achieved by observing swallowing patterns and throat assessment rather than waiting for emesis.
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Full Explanation
Postoperative care following a tonsillectomy focuses on monitoring for complications such as hemorrhage, airway obstruction, and dehydration. Because the surgical site is highly vascular, bleeding is the most serious early complication. Children may swallow blood instead of spitting it out, making subtle signs of hemorrhage especially important to detect. Nurses must closely observe for early indicators of bleeding and airway compromise to ensure prompt intervention.
Rationale:
A. Continuous swallowing is a key early sign of postoperative hemorrhage after tonsillectomy. Blood from the surgical site may trickle into the throat and be swallowed repeatedly, especially in children who cannot verbalize symptoms effectively. This behavior often precedes visible bleeding and requires immediate assessment and intervention.
B. Inflamed throat is an expected postoperative finding following tonsillectomy due to surgical tissue trauma. Mild to moderate throat inflammation, pain, and redness are normal during the healing process. This finding alone does not indicate a complication unless it is accompanied by signs of infection or bleeding.
C. Impaired taste is not a common or clinically significant complication following tonsillectomy. Temporary taste changes may occur due to swelling or discomfort, but they are not considered a warning sign of postoperative complications. This symptom is usually transient and resolves with healing.
D. Dark blood in emesis may indicate partially digested blood but is not as reliable or early a sign of hemorrhage as continuous swallowing. It can suggest bleeding, but it often appears after blood has accumulated in the stomach. Early detection is more effectively achieved by observing swallowing patterns and throat assessment rather than waiting for emesis.
Similar Questions
A nurse is caring for a school-age child who has a new prescription for Buck's traction. Which of the following actions should the nurse take?
A. Adjust the weights to allow the child to turn.
Adjusting the weights to allow the child to turn is incorrect because the traction system must remain continuous and properly aligned at all times. Weights should hang freely without interference to maintain consistent traction force. Altering or adjusting weights can disrupt alignment and compromise treatment effectiveness.
B. Perform pin care every 24 hr.
Performing pin care every 24 hours is incorrect because Buck’s traction is a skin traction system and does not involve pins. Pin care is only required for skeletal traction where pins are inserted into bone. Since Buck’s traction uses straps and adhesive, pin care is not applicable.
C. Ensure the pulley mechanism is attached to the child' skin.
Ensuring the pulley mechanism is attached to the child’s skin is incorrect because the pulley system is not attached to the skin but to the traction frame or bed. The skin is only involved through adhesive traction materials. Attaching mechanical components to the skin would be unsafe and inappropriate.
D. Offer opioid medications frequently to reduce pain.
Offering opioid medications frequently to reduce pain is appropriate because Buck’s traction and underlying fracture can cause significant pain. Adequate pain control promotes comfort, cooperation, and effective alignment. Opioids are commonly used for moderate to severe pain in pediatric orthopedic injuries when appropriately prescribed and monitored.
Full Explanation
Buck’s traction is a form of skin traction commonly used in pediatric clients with lower extremity fractures to reduce muscle spasms, maintain alignment, and promote comfort prior to definitive treatment. It involves applying a pulling force using weights and a pulley system. Proper nursing care focuses on maintaining correct alignment, preventing complications, and ensuring adequate pain control. Because fractures and traction can cause significant discomfort, effective analgesia is an important part of care.
Rationale:
A. Adjusting the weights to allow the child to turn is incorrect because the traction system must remain continuous and properly aligned at all times. Weights should hang freely without interference to maintain consistent traction force. Altering or adjusting weights can disrupt alignment and compromise treatment effectiveness.
B. Performing pin care every 24 hours is incorrect because Buck’s traction is a skin traction system and does not involve pins. Pin care is only required for skeletal traction where pins are inserted into bone. Since Buck’s traction uses straps and adhesive, pin care is not applicable.
C. Ensuring the pulley mechanism is attached to the child’s skin is incorrect because the pulley system is not attached to the skin but to the traction frame or bed. The skin is only involved through adhesive traction materials. Attaching mechanical components to the skin would be unsafe and inappropriate.
D. Offering opioid medications frequently to reduce pain is appropriate because Buck’s traction and underlying fracture can cause significant pain. Adequate pain control promotes comfort, cooperation, and effective alignment. Opioids are commonly used for moderate to severe pain in pediatric orthopedic injuries when appropriately prescribed and monitored.
A nurse is caring for a child who has impetigo contagiosa that developed in the hospital. Which of the following actions should the nurse take?
A. Initiate contact isolation precautions.
Initiating contact isolation precautions is correct because impetigo is spread through direct skin-to-skin contact and contaminated surfaces. Contact precautions include gloves, gown use, and proper hand hygiene to prevent transmission. This is essential in a hospital setting to control nosocomial spread of the infection.
B. Administer amphotericin B IV.
Amphotericin B IV is an antifungal medication used for severe systemic fungal infections, not bacterial skin infections like impetigo. Since impetigo is caused by bacteria, antifungal therapy is ineffective and inappropriate. Antibiotics, either topical or systemic, are the correct treatment approach.
C. Report the disease to the state health department.
Reporting the disease to the state health department is not required for impetigo contagiosa because it is a common, non-reportable skin infection. It requires infection control measures within the hospital, but it does not meet criteria for mandatory public health reporting.
D. Apply lidocaine ointment topically.
Applying lidocaine ointment topically is not appropriate because impetigo does not typically cause pain requiring local anesthetic treatment. The condition is managed with antibacterial therapy rather than symptomatic anesthetic relief. Additionally, topical anesthetics may irritate broken skin and are not indicated.
Full Explanation
Impetigo contagiosa is a highly contagious superficial bacterial skin infection commonly caused by Staphylococcus aureus or Streptococcus pyogenes. It is characterized by honey-colored crusted lesions and spreads easily through direct contact with infected skin or contaminated objects. In the hospital setting, preventing transmission is a priority to protect other patients and healthcare workers. Infection control measures are essential alongside antibiotic therapy to limit spread.
Rationale:
A. Initiating contact isolation precautions is correct because impetigo is spread through direct skin-to-skin contact and contaminated surfaces. Contact precautions include gloves, gown use, and proper hand hygiene to prevent transmission. This is essential in a hospital setting to control nosocomial spread of the infection.
B. Amphotericin B IV is an antifungal medication used for severe systemic fungal infections, not bacterial skin infections like impetigo. Since impetigo is caused by bacteria, antifungal therapy is ineffective and inappropriate. Antibiotics, either topical or systemic, are the correct treatment approach.
C. Reporting the disease to the state health department is not required for impetigo contagiosa because it is a common, non-reportable skin infection. It requires infection control measures within the hospital, but it does not meet criteria for mandatory public health reporting.
D. Applying lidocaine ointment topically is not appropriate because impetigo does not typically cause pain requiring local anesthetic treatment. The condition is managed with antibacterial therapy rather than symptomatic anesthetic relief. Additionally, topical anesthetics may irritate broken skin and are not indicated.
A nurse is assessing a client who is receiving radiation therapy to the chest. The client reports having an area of dry skin where they received radiation. Which of the following interventions should the nurse suggest to the client?
A. Apply an over-the-counter skin lotion to the area as needed.
Applying an over-the-counter skin lotion as needed is not recommended unless specifically approved by the radiation oncology provider. Many lotions contain perfumes, alcohol, or other irritants that can worsen skin breakdown or interfere with radiation effects. Only prescribed or approved products should be used on irradiated skin.
B. Clean the area daily with a solution of chlorhexidine and water.
Cleaning the area daily with chlorhexidine and water is inappropriate because chlorhexidine can be too harsh and may further irritate already sensitive radiation-treated skin. The area should be washed gently with mild soap and lukewarm water, avoiding strong antiseptics. Harsh cleansing agents increase dryness and discomfort.
C. Cover the area with protective clothing if exposed to the sun.
Covering the area with protective clothing if exposed to the sun is correct because irradiated skin becomes highly sensitive to sunlight and can burn easily. Direct sun exposure can worsen dryness, erythema, and tissue damage. Loose, soft clothing helps protect the area while minimizing friction and additional irritation.
D. Remove skin markings for the radiation fields following therapy.
Removing skin markings for the radiation fields is incorrect because these markings guide accurate and consistent delivery of radiation therapy. Erasing them may disrupt treatment precision and require remarking by the provider. Clients should be instructed to preserve these markings until treatment is completed.
Full Explanation
Radiation therapy to the chest commonly causes localized skin reactions because rapidly dividing skin cells are sensitive to radiation exposure. Clients may develop dryness, erythema, peeling, and irritation in the treatment field, similar to a sunburn. Nursing care focuses on protecting the affected skin, preventing further irritation, and promoting healing without disrupting treatment planning. Proper skin care teaching is essential to reduce complications and improve comfort during therapy.
Rationale:
A. Applying an over-the-counter skin lotion as needed is not recommended unless specifically approved by the radiation oncology provider. Many lotions contain perfumes, alcohol, or other irritants that can worsen skin breakdown or interfere with radiation effects. Only prescribed or approved products should be used on irradiated skin.
B. Cleaning the area daily with chlorhexidine and water is inappropriate because chlorhexidine can be too harsh and may further irritate already sensitive radiation-treated skin. The area should be washed gently with mild soap and lukewarm water, avoiding strong antiseptics. Harsh cleansing agents increase dryness and discomfort.
C. Covering the area with protective clothing if exposed to the sun is correct because irradiated skin becomes highly sensitive to sunlight and can burn easily. Direct sun exposure can worsen dryness, erythema, and tissue damage. Loose, soft clothing helps protect the area while minimizing friction and additional irritation.
D. Removing skin markings for the radiation fields is incorrect because these markings guide accurate and consistent delivery of radiation therapy. Erasing them may disrupt treatment precision and require remarking by the provider. Clients should be instructed to preserve these markings until treatment is completed.