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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Barking cough is not a finding that indicates the effectiveness of the treatment. Barking cough is a sign of inflammation of the larynx and trachea, which causes a hoarse and harsh sound. It is a common symptom of acute laryngotracheobronchitis, also known as croup.
Choice B reason: Decreased stridor is a finding that indicates the effectiveness of the treatment. Stridor is a high-pitched, wheezing sound that occurs when the airway is narrowed or obstructed. It is a sign of respiratory distress and hypoxia. The cool mist tent helps to humidify and soothe the airway, reducing the swelling and inflammation.
Choice C reason: Decreased temperature is not a finding that indicates the effectiveness of the treatment. Decreased temperature could be a sign of hypothermia or sepsis, which are serious complications that require immediate attention. The normal temperature range for a toddler is 36.5°C to 37.5°C (97.7°F to 99.5°F).
Choice D reason: Improved hydration is not a finding that indicates the effectiveness of the treatment. Improved hydration is a sign of adequate fluid intake and output, which are important for maintaining electrolyte balance and preventing dehydration. However, hydration status does not directly affect the airway inflammation or obstruction.
Correct Answer is C
Explanation
Choice A reason: This statement is incorrect, as giving an oral rehydration solution to an infant who is projectile vomiting may worsen the dehydration and electrolyte imbalance. The nurse should advise the parent to stop feeding the infant and seek medical attention.
Choice B reason: This statement is incorrect, as burping the baby more frequently during feedings may not prevent the projectile vomiting, which is caused by a mechanical obstruction of the stomach, not by air swallowing. The nurse should assess the parent for signs of pyloric stenosis, such as a palpable olive-shaped mass in the right upper quadrant of the abdomen.
Choice C reason: This statement is correct, as bringing the baby in to the clinic today is the best course of action for an infant who is projectile vomiting, which is a sign of a serious condition such as pyloric stenosis, a narrowing of the opening between the stomach and the small intestine. The nurse should inform the parent that the infant needs immediate evaluation and treatment to prevent complications such as dehydration, malnutrition, and metabolic alkalosis.
Choice D reason: This statement is incorrect, as trying switching to a different formula may not help the infant who is projectile vomiting, which is not related to the type of formula, but to a structural problem in the gastrointestinal tract. The nurse should not suggest changing the formula without consulting the provider.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today