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 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.
Correct Answer is B
Explanation
The nurse should initiate droplet isolation precautions when admitting a child who has acute epiglottitis.
Epiglottitis is commonly caused by Haemophilus influenzae type B and can be transmitted through respiratory droplets.
Choice A is wrong because obtaining a throat culture is not recommended when epiglottitis is suspected, as it can cause further obstruction of the airway.
Choice C is wrong because assisting the child into a supine position can worsen the airway obstruction.
Children with epiglottitis prefer to sit upright with the chin extended and mouth open.
Choice D is wrong because checking oxygen saturation every 4 hours may not be frequent enough for a child with acute epiglottitis who may require continuous monitoring of oxygen saturation.
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