Reposting Tonsilectomy question...

Nurses General Nursing

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Hello, Student here. This test question is driving me crazy. I prevuosly posted this question, but reposting d/t gave wrong info in one of the answers. Question; 10 yr old pt comes up on floor following a tonsilectomy. What would be the first thing the nurse would address?

A. dark brown emesis

B. falls asleep during assessment

In my textbook it clearly states that dark brown emesis is a normal finding here. I chose B d/t how can you asume the pt fell asleep, couldn't this be a change in level of conscisness possibly from trauma from surgery? I would think that you you first further assess to make sure that that this pt is just sleeping. However, the correct answer from my teacher was A. Don't understand why it would not be B. Your thaughts?

I didn't peek thru the rest of the answers but this question and the answer is an NCLEX type question.

The answer is A b/c in case of any emesis, you would immediately turn the child over onto their side to prevent aspiration, with head and neck turned to the side.

Falling asleep after anesthesia is a normal finding.

Always think ABC's with these type of questions

This is an Airway concern.

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I'd go with the dark emesis answer, too.

The question says what would you address. I would address the vomiting (even though the text says this is a normal thing with this surgery). No one is saying that its not normal to see this. But you would want to address it to make sure that the pt has ABC's..which always come first over everything.

If the pt is vomiting his/her airway could be compromised, they might be aspiriating on the vomit etc.

Falling asleep during assessment is also common of anesthesia. But honestly, its not life threatening like vomiting with a LOC change is.

Think about it this way. You are an ER nurse, you have a person come in drunk (or so you think) due to the LOC. The person is also vomiting (pick any color, lets even say bright red). The FIRST thing you are going to address is the vomiting, you are going to position the pt on their side, you are going to ensure an open airway, suction out the emesis and then you will address the LOC. Because in all honesty, even if it is a LOC from something other than being drunk, what good is fixing that LOC problem if the pt is choking to death on their own vomit? If you allow them to do that, there is still going to be a LOC...its called dead.

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Well said. Ugh........ this kind question is gonna fail me on tests:bluecry1:. Two semesters to go.....oh boy!

I think Daytonite and Icyounurse have given perfect information as to why answer A is correct as well. You mentioned in the beginning that you might be reading too much into the question- but I think it is the answer you are reading too much in to. You asked how you could assume that the pt just fell asleep during the assessment, but that is exactly what the answer choice states. It doesn't say something like "pt's head falls back on pillow during assessment", if it did then you would be making an assumption as to whether or not the pt fell asleep. It clearly says the pt is sleeping.

In addition, as other have stated, you must "address" emesis. If not for the bleeding issue that would be suggested with dark brown emesis, it would be for the airway issue of aspiration.

When answering questions it helps me to decide from the beginning if I need to assess or implement and then go with ABC's and then on to Maslow. In your mind if you begin to think "but what if..." you are beginning to read too much in to it.

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Thank you, after getting some sleep and coming back and reading all the posts it is finaly making sense to me why the correct answer is A:rolleyes:.

I'd go with the dark emesis answer, too.

The question says what would you address. I would address the vomiting (even though the text says this is a normal thing with this surgery). No one is saying that its not normal to see this. But you would want to address it to make sure that the pt has ABC's..which always come first over everything.

If the pt is vomiting his/her airway could be compromised, they might be aspiriating on the vomit etc.

Falling asleep during assessment is also common of anesthesia. But honestly, its not life threatening like vomiting with a LOC change is.

Think about it this way. You are an ER nurse, you have a person come in drunk (or so you think) due to the LOC. The person is also vomiting (pick any color, lets even say bright red). The FIRST thing you are going to address is the vomiting, you are going to position the pt on their side, you are going to ensure an open airway, suction out the emesis and then you will address the LOC. Because in all honesty, even if it is a LOC from something other than being drunk, what good is fixing that LOC problem if the pt is choking to death on their own vomit? If you allow them to do that, there is still going to be a LOC...its called dead.

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Thankyou thankyou for your rationale b/c it makes sense now that you have broken it down to this simplicity:wink2:!

You are overthinking it, which is a common problem for many in nursing school. Its actually very simple. Maslow's is a great way to answer these questions as daytonite pointed out. I always did ABC's myself for many NCLEX questions too.

1st is always A=Airway, then B=breathing, and then look to C=circulation.

Is change of LOC an immediate threat to the airway, breathing, or circulation??

No its not.

Is vomiting in a post op tonsillectomy an immediate threat to the airway??

You betcha.

So while it is not wrong persay to choose to further assess LOC, it is not the most immediate thing that needs to be done. On NCLEX you will find that more than one anwser is correct, but the trick is you have to pick the most correct. And the emesis is simply the most correct of the 2 in this case.

Does this help any??

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okay i will now put this question to rest. after reading the many posts from you and the other nurses how could i possibly still argue my point:confused:. it does make sense to me now that the correct answer would be a. if they keep asking this from of question.....i will fail for sure! thank you for all your help with this:bow:.

so basicaly the pt suddenly falls asleep during assesment could not actualy indicate a possible change in loc d/t possible trauma from surgery which could then lead to aspiration of emesis is not a possibility?

look up the effects of anesthesia. you are merging two answer choices into one. you can't do that. that's how the writers of these questions trip you up. they do it deliberately to see who is using rational thinking and reading carefully. an answer choice does not contribute to the given information in the stem of the question and is only an answer choice.

and address is "to do something about", well isn't assessing loc addressing a potential problem?

yes, but emesis is a potentially bigger problem. sleepiness from anesthesia is expected and nothing else indicates it is damaging at the moment. emesis has consequences and it needs to be put under control asap.

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Specializes in med/surg, telemetry, IV therapy, mgmt.
If they keep asking this from of question.....I will fail for sure! Thank you for all your help with this:bow:.

You can't think that way. These kinds of questions will be asked because they are trying to stimulate you to think critically. Always go back to the stem of the question and focus on that. Cover up all the other answer choices and consider each answer choice separately in respect to the stem of the question first. Be very careful when comparing answer choices with each other and do not make the wrong answer part of the information included in the stem of the question. The test question writers deliberately design questions that way to trip up people's critical thinking. Since you are already an LPN you are particularly vulnerable to some of these tactics because you've most likely seen a lot of errors in practice and that's what they base some of these answer choices on. So you need to be very careful. Remember: there is almost always a principle behind the answers to these questions unless it involves straight out knowledge of a drug. What you know, your practical experience, is only going to help you so much--you must know and be able to apply those underlying principles. As my instructors always harped at us, you must know why you are making those choices.

Hang in there. We all went through this. :loveya:

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Okay I will now put this question to rest. After reading the many posts from you and the other nurses how could I possibly still argue my point:confused:. It does make sense to me now that the correct answer would be A. If they keep asking this from of question.....I will fail for sure! Thank you for all your help with this:bow:.

It really isn't that bad... just ask your self when reading through the answers "is this an airway, breathing, or circulation issue?". If you can answer yes to more than one then prioritize with airway, but if you can answer yes to only one then that is your answer.

I can understand where you are coming from though... when I was first starting out I thought a decreased level of consciousness was the worst thing, I guess I pictured them basically coding and everything stopping at once (heart rate, breathing, etc.). Maybe it's based on the type of thing you see on tv. Assessing LOC and watching for changes is a priority, but not over a compromised airway or cardiac arrest from what I have understood. I hope that makes some sort of sense. :chuckle

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Thanks to all of your posts, they have been great help. I'd like to ask one more question........I know I know, but I need to know this for future questions. The question was something like; 15 year old comes to ER with Aspirin poisioning. The nurse would take which action?

A. administer activated charcoal

B. apply cooling blanket

Now, activated charcoal is the form of tx for this but it does not state anywhere that the MD ordered this. I chose cooling blanket b/c that is an intervention for this condition. When it comes to medication I thaught you would need to see something stateing it was ordered for the med to be the correct answer OR the question would have to ask what would the nurse EXPECT to do? So when taking exams am I supposed to assume all meds listed in answers were ordered? This question threw me to cauase a question further down the test actually stated in the question "MD ordered all of the following."

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Specializes in med/surg, telemetry, IV therapy, mgmt.
thanks to all of your posts, they have been great help. i'd like to ask one more question........i know i know, but i need to know this for future questions. the question was something like; 15 year old comes to er with aspirin poisioning. the nurse would take which action?

a. administer activated charcoal

b. apply cooling blanket

now, activated charcoal is the form of tx for this but it does not state anywhere that the md ordered this. i chose cooling blanket b/c that is an intervention for this condition. when it comes to medication i thaught you would need to see something stateing it was ordered for the med to be the correct answer or the question would have to ask what would the nurse expect to do? so when taking exams am i supposed to assume all meds listed in answers were ordered? yes this question threw me to cauase a question further down the test actually stated in the question "md ordered all of the following."

when problem solving, use the nursing process to help you:

  • assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
    • a physical assessment of the patient
    • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
    • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
    • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
    • https://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html - medical disease information/treatment/procedures/test reference websites
      • you have been given information here that the patient has aspirin poisoning. look up the signs and symptoms of aspirin poisoning and how the physicians treat it:
      • treatments are given based on doing away with the cause of the problem altogether and treating the patient symptoms. symptoms are manifestations of the pathophysiology of the disease process and they occur as the disease process worsens. so, what is going on and how badly into the pathophysiology is it? symptoms of aspirin overdose are (http://www.emedicinehealth.com/aspirin_poisoning/page3_em.htm):
        • severe deep and rapid breathing, prominent nervous system disturbances, such as marked lethargy or excitability, but no coma or convulsions

        the medical treatment is aimed at preventing further absorption of aspirin, correcting dehydration and acid-base abnormalities, and reducing the amount of salicylate in the body by increasing the rate at which the body can get rid of it (http://www.emedicinehealth.com/aspirin_poisoning/page7_em.htm):

        • gastric lavage within 60 minutes after the ingestion to remove as much of the aspirin from the stomach before absorption into the blood as possible, dialysis once the salicylates gave gone into the blood, give activated charcoal to absorb the salicylate + laxatives to move it out of the body, iv fluids for dehydration, give sodium bicarbonate to promote diuresis of alkaline compounds (the salicylates), tracheostomy, foley catheter

you don't need to go any further in problem solving this because the answer is already there. . .

-->administer activated charcoal
- this
is
a treatment for aspirin od and likely that the er doctor will order it

apply cooling blanket
- fever is
not
a symptom of aspirin od, it is not likely that a fever is occurring because of aspirin poisoning

i chose cooling blanket b/c that is an intervention for this condition.

is it? why is a cooling blanket used? when there are high fevers. where does the stem of the problem mention that the patient has a fever? it doesn't. do not assume that because you see the drug aspirin that there must have been a fever. for all we know, the kid decided to commit suicide or someone dared him to swallow a bottle of pills to see how fast the ambulance came. who knows? but from looking up the symptoms of aspirin poisoning we know that a fever isn't even on the list of symptoms, so by default alone giving activated charcoal wins the argument whether you have a doctor's order or not. it would be a collaborative intervention (one requiring a doctor's order). if the doc didn't order it, you would speak up and ask for it if you found out the ingestion of aspirin had taken place recently because you knew from your knowledge of aspirin poisoning (see website referenced above) that there was still some aspirin in their stomach and you needed to get charcoal in the stomach to bind to it and prevent it from getting into their blood stream.

that is how you critical think these answers out. i didn't know the answer to this. that's why i went to the emedicinehealth site for some help. you should do the same to verify things. i am a med/surg nurse.

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thanks again! i only choose the cooling blanket b/c it was listed in my course outline under nursing interventions for asa posioning and was also said in lecture but she did not give rationale why. i knew what the treatment was, but i did not choose it b/c thaught it was the wrong answer and teacher would say "you can't just give that without md order."

i looked into many of the recomended threads you sent me, and i found exactly what i keep doing; do not "yes, but" questions. this is what is meant by reading into questions and answers. saying "yes, but if the client.......then......." is a particular temptation for students who have realy studied and know more than is actually on the test.

i do this all the time and hard for me to break from this. i have my lpn and another degree and have never had such difficulty taking tests. however, i was diagnosed with add one year ago, wonder if that has something to do with this. our exams are 28 questions and 30 minutes to answer, having trouble finishing on time, i'm rushed. it's like they are testing how fast you recall something rather than what you actually know. this is the learning process:banghead:.

when problem solving, use the nursing process to help you:

  • assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
    • a physical assessment of the patient
    • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
    • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
    • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
    • https://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html - medical disease information/treatment/procedures/test reference websites
      • you have been given information here that the patient has aspirin poisoning. look up the signs and symptoms of aspirin poisoning and how the physicians treat it:
      • treatments are given based on doing away with the cause of the problem altogether and treating the patient symptoms. symptoms are manifestations of the pathophysiology of the disease process and they occur as the disease process worsens. so, what is going on and how badly into the pathophysiology is it? symptoms of aspirin overdose are (http://www.emedicinehealth.com/aspirin_poisoning/page3_em.htm):
        • severe deep and rapid breathing, prominent nervous system disturbances, such as marked lethargy or excitability, but no coma or convulsions

        the medical treatment is aimed at preventing further absorption of aspirin, correcting dehydration and acid-base abnormalities, and reducing the amount of salicylate in the body by increasing the rate at which the body can get rid of it (http://www.emedicinehealth.com/aspirin_poisoning/page7_em.htm):

        • gastric lavage within 60 minutes after the ingestion to remove as much of the aspirin from the stomach before absorption into the blood as possible, dialysis once the salicylates gave gone into the blood, give activated charcoal to absorb the salicylate + laxatives to move it out of the body, iv fluids for dehydration, give sodium bicarbonate to promote diuresis of alkaline compounds (the salicylates), tracheostomy, foley catheter

you don't need to go any further in problem solving this because the answer is already there. . .

-->administer activated charcoal
- this
is
a treatment for aspirin od and likely that the er doctor will order it

apply cooling blanket
- fever is
not
a symptom of aspirin od, it is not likely that a fever is occurring because of aspirin poisoning

i chose cooling blanket b/c that is an intervention for this condition.

is it? why is a cooling blanket used? when there are high fevers. where does the stem of the problem mention that the patient has a fever? it doesn't. do not assume that because you see the drug aspirin that there must have been a fever. for all we know, the kid decided to commit suicide or someone dared him to swallow a bottle of pills to see how fast the ambulance came. who knows? but from looking up the symptoms of aspirin poisoning we know that a fever isn't even on the list of symptoms, so by default alone giving activated charcoal wins the argument whether you have a doctor's order or not. it would be a collaborative intervention (one requiring a doctor's order). if the doc didn't order it, you would speak up and ask for it if you found out the ingestion of aspirin had taken place recently because you knew from your knowledge of aspirin poisoning (see website referenced above) that there was still some aspirin in their stomach and you needed to get charcoal in the stomach to bind to it and prevent it from getting into their blood stream.

that is how you critical think these answers out. i didn't know the answer to this. that's why i went to the emedicinehealth site for some help. you should do the same to verify things. i am a med/surg nurse.

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Specializes in Addictions, Corrections, QA/Education.

The question doesn't state that the patient suddenly fell asleep. As others have said... pt's are 'loopy' after anesthesia. Generally, when a patient comes from surgery you assess there VS frequently anyway. You look at them... you should be able to tell if there are having a decreased LOC. They should arouse easily. If the patient vomited, I would address that first.

Nursing test (and board) questions can be tricky. I was always told NOT to read too much into the question. There are many scenarios that "could" be and there are many "what if's". When you are answering these questions don't go into the what if's.

Im sorry... I hope you get clarification from your instructor.

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