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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The first action the nurse should take is to elevate the child’s leg.
This is choice A. Elevating the child’s leg can help reduce swelling and improve circulation.
After elevating the child’s leg, the nurse can then administer pain medication (choice B), petal the edges of the cast (choice C), and teach the child about cast care (choice D).
Correct Answer is C
Explanation
A preschool-age child who has a muffled voice and no spontaneous cough should be assessed first.
These symptoms may indicate epiglottitis, which is a life-threatening condition that requires immediate medical attention.
Choice A, B and D are also important but not as urgent as choice C. A toddler with nephrotic syndrome and facial edema, an adolescent with Crohn’s disease and recent weight loss, and a school-age child with diabetes mellitus and a blood glucose of 200 mg/dL should be assessed after the preschool-age child with a muffled voice and no spontaneous cough.
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