A nurse is caring for a child in the PACU following a tonsillectomy.
Which of the following finding requires immediate intervention by the nurse should the nurse?
Dark brown blood noted in emesis
Frequent swallowing
Axillary temperature of 38 C (100 f)
Child reports pain level of 5 on the FACES scale
The Correct Answer is B
The correct answer is choice B.
Choice A rationale:
Dark brown blood in emesis is typically old blood and may not require immediate intervention. However, it should still be monitored and reported to the healthcare provider.
Choice B rationale:
Frequent swallowing can indicate active bleeding from the surgical site, which requires immediate intervention. This is a sign that the child may be swallowing blood, which can lead to significant blood loss.
Choice C rationale:
An axillary temperature of 38°C (100°F) is a mild fever and not uncommon postoperatively. It should be monitored, but it does not require immediate intervention.
Choice D rationale:
A pain level of 5 on the FACES scale indicates moderate pain, which is expected after a tonsillectomy. Pain management should be addressed, but it does not require immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
Choice A rationale
Providing a pacifier coated with an oral sucrose prior to injections can help reduce the infant’s pain response. The sweetness of the sucrose can distract the infant and provide some comfort.
Choice B rationale
Injecting the immunizations into the deltoid muscle is not recommended for infants. The deltoid muscle is not usually used until children are older and have more muscle mass.
Choice C rationale
Using a 20-gauge needle for injections is not typically recommended for infants. Smaller gauge needles are usually used to minimize discomfort.
Choice D rationale
Applying a eutectic mixture of local anesthetics cream immediately before the injections can help numb the skin and reduce pain. This can make the injection process less distressing for the infant.
Correct Answer is A
Explanation
Choice A rationale
A child who has a fractured left femur would be an appropriate roommate for a preschooler following Wilms’ tumor removal. This child does not have a contagious condition that would pose a risk to the preschooler.
Choice B rationale
A child who has cellulitis of the right radius would not be an appropriate roommate for a preschooler following Wilms’ tumor removal. Cellulitis is a bacterial skin infection and could potentially pose a risk of infection to the preschooler, who may have a compromised immune system after surgery.
Choice C rationale
A child who has impetigo would not be an appropriate roommate for a preschooler following Wilms’ tumor removal. Impetigo is a highly contagious skin infection and could pose a risk of infection to the preschooler.
Choice D rationale
A child who has viral pneumonia would not be an appropriate roommate for a preschooler following Wilms’ tumor removal. Pneumonia is a contagious respiratory infection and could pose a risk to the preschooler, especially if their immune system is compromised after surgery.
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