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 D
Explanation
Choice A rationale
Administering methylprednisolone, a corticosteroid, can help reduce inflammation. However, it is not the first-line treatment for severe anaphylaxis.
Choice B rationale
Administering oxygen can help improve the child’s oxygenation, but it is not the first action the nurse should take in this situation.
Choice C rationale
Administering a nebulized bronchodilator can help relieve wheezing, but it is not the first action the nurse should take in this situation.
Choice D rationale
Administering epinephrine is the first-line treatment for anaphylaxis. It works quickly to improve breathing, stimulate the heart, raise a dropping blood pressure, and reduce swelling of the face, lips, and throat.
Correct Answer is D
Explanation
Choice A rationale
Having a vocabulary of 30 words is not a finding that should be reported to the provider for a 24-month-old toddler. By 24 months, most children can say 50 words or more.
Choice B rationale
Sleeping 11 to 12 hours per day is not a finding that should be reported to the provider for a 24-month-old toddler. This is a typical amount of sleep for a child this age.
Choice C rationale
Eating a large amount of food one day then very little the next is not a finding that should be reported to the provider for a 24-month-old toddler. Toddlers often have variable appetites, and it’s normal for them to eat more on some days and less on others.
Choice D rationale
Holding his breath when having a temper tantrum is a finding that should be reported to the provider for a 24-month-old toddler. While breath-holding spells can be a normal part of toddler behavior, they can also be a sign of an underlying medical condition. It’s important for the provider to evaluate this behavior to rule out any potential health concerns.
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