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    ATI RN Capstone Proctored Comprehensive Assessment A

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    Question: 1 of 80Ati rn capstone proctored comprehensive assessment A
    A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings should the nurse identify as the priority?
    Explanation
    A. Sore throat – A sore throat is expected following a tonsillectomy due to the surgical site trauma. It is not an immediate concern unless accompanied by other abnormal findings such as severe pain or difficulty breathing. B. Blood-tinged mucus – Small amounts of blood-tinged mucus are normal after surgery. However, active bleeding would present as bright red blood rather than a small amount of tinged mucus. C. Frequent swallowing – This is the priority finding because it may indicate active bleeding at the surgical site. Children may not always report bleeding but may swallow frequently as blood drips into their throat. If left undetected, excessive bleeding can lead to hemorrhage and airway compromise. The nurse should inspect the throat immediately and notify the provider. D. Dark brown emesis – Vomiting old blood (which appears dark brown) may occur if the child swallowed some blood postoperatively. While this should be monitored, it is not as concerning as active bleeding, which presents as bright red blood.
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