A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings is a manifestation of hemorrhage?
Drooling
Poor fluid intake
Increased pain
Frequent swallowing
The Correct Answer is D
Choice A reason: Drooling is not a sign of hemorrhage, but rather a sign of difficulty swallowing or breathing. Drooling may occur after a tonsillectomy due to throat pain or swelling, but it does not indicate bleeding.
Choice B reason: Poor fluid intake is not a sign of hemorrhage, but rather a sign of dehydration or nausea. Poor fluid intake may occur after a tonsillectomy due to throat pain or fear of swallowing, but it does not indicate bleeding.
Choice C reason: Increased pain is not a sign of hemorrhage, but rather a sign of inflammation or infection. Increased pain may occur after a tonsillectomy due to tissue damage or healing, but it does not indicate bleeding.
Choice D reason: Frequent swallowing is a sign of hemorrhage, as it indicates that the child is trying to clear blood from the throat. Frequent swallowing may occur after a tonsillectomy due to bleeding from the surgical site or a ruptured blood vessel.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Oral rehydration solution (ORS) is the best fluid for a child with acute gastroenteritis, as it contains the optimal balance of electrolytes and glucose to prevent dehydration and restore fluid balance. ORS is recommended by the World Health Organization (WHO) and the American Academy of Pediatrics (AAP) for the management of diarrhea in children.
Choice B reason: Water is not a good fluid for a child with acute gastroenteritis, as it does not contain any electrolytes or glucose and can dilute the blood sodium level, leading to hyponatremia. Water can also increase the osmotic load in the intestines and worsen diarrhea.
Choice C reason: Broth is not a good fluid for a child with acute gastroenteritis, as it is high in sodium and can cause hypernatremia and dehydration. Broth can also irritate the intestinal mucosa and increase diarrhea.
Choice D reason: Diluted apple juice is not a good fluid for a child with acute gastroenteritis, as it is high in fructose and can cause osmotic diarrhea. Apple juice can also lower the blood pH and cause metabolic acidosis.
Correct Answer is C
Explanation
Choice A reason: Obtaining blood culture specimens is important to identify the causative organism and guide antibiotic therapy, but it is not the priority action for a child who is in respiratory distress. The nurse should first secure the airway and stabilize the child's condition.
Choice B reason: Administering an antipyretic may help lower the fever and reduce discomfort, but it does not address the cause of the dyspnea and drooling, which may indicate epiglottitis. This is a life-threatening condition that requires immediate airway management.
Choice C reason: Preparing for nasotracheal intubation is the priority action for a child who has signs of epiglottitis, as it can prevent airway obstruction and respiratory failure. The nurse should have the equipment and personnel ready for intubation and avoid any stimulation or manipulation of the throat that can trigger laryngeal spasm.
Choice D reason: Inserting an IV catheter is necessary to administer fluids and medications, but it is not the first priority for a child who is in respiratory distress. The nurse should focus on the airway before the circulation.
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