A nurse is caring for a 5-year-old child following a tonsillectomy and adenoidectomy.
Which of the following findings should the nurse identify as an indication of hemorrhage?
Blood pressure 95/56 mm Hg.
Heart rate 54/min.
Continuous swallowing.
Flushing of the face.
The Correct Answer is C
Continuous swallowing can be an indication of hemorrhage following a tonsillectomy and adenoidectomy.
This is because the child may be swallowing blood that is coming from the surgical site.
Choice A is wrong because a blood pressure of 95/56 mm Hg is within the normal range for a 5-year-old child.
Choice B is wrong because a heart rate of 54/min is within the normal range for a 5-year-old child.
Choice D is wrong because flushing of the face is not an indication of hemorrhage following a tonsillectomy and adenoidectomy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Ataxia is a neurological sign that refers to a lack of muscle coordination and can cause staggering. Inhalation of gasoline vapors can cause symptoms such as dizziness or lightheadedness, headache, facial flushing, coughing or wheezing, staggering, slurred speech, blurry vision and weakness.
Choice B is wrong because Hypothermia is not an answer because hypothermia refers to a dangerously low body temperature and is not a symptom of gasoline inhalation.
Choice C is wrong because Hyperactive reflexes are not an answer because hyperactive reflexes refer to overactive or overresponsive reflexes and are not a symptom of gasoline inhalation.
Choice D is wrong because Pinpoint pupils are not an answer because pinpoint pupils refer to abnormally small pupils and are not a symptom of gasoline inhalation.
Correct Answer is D
Explanation
A. Incorrect because the bag should only cover the urethral opening. Covering the anus risks contamination of the urine sample.
B.Incorrect because placing a diaper over the bag can dislodge it or prevent proper adhesion. Instead, the bag should remain exposed to adhere well.
C.Incorrect because lidocaine is unnecessary; applying topical anesthetic is not required for urine collection with a bag.
D. When collecting a urine specimen from a female infant using a urine collection bag, the nurse should ensure the perineal area is clean and the skin is dry. Stretching the perineum taut helps the bag adhere properly to the skin around the urethral opening, preventing leaks and contamination of the specimen.
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