A nurse is caring for a child in the PACU following a tonsillectomy. Which of the following findings requires immediate intervention by the nurse?
Dark brown blood noted in emesis
Axillary temperature 38° C (100° F)
Child reports pain level of 5 on the FACES scale
Frequent swallowing
The Correct Answer is D
A. Dark brown blood in emesis is expected postoperatively due to swallowed blood and does not require immediate intervention.
B. A mild fever (38°C or 100°F) can occur postoperatively and is not an emergency.
C. Pain is expected after a tonsillectomy and should be managed but does not require immediate intervention.
D. Frequent swallowing may indicate active bleeding from the surgical site, which requires immediate assessment and intervention.
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Related Questions
Correct Answer is A
Explanation
A. This is the correct statement. Children with HIV are at increased risk for tuberculosis (TB) infection. Therefore, regular testing for TB is an important part of their healthcare.
B. Doubling medications without specific guidance from the healthcare provider can be dangerous and is not recommended. It's important for the parent to follow the prescribed medication regimen as directed.
C. While zidovudine (AZT) is an important medication for HIV treatment, the statement is not accurate. The risk of transmission does not decrease after only 2 weeks of
treatment. It takes longer for the viral load to decrease significantly.
D. Children with HIV do not necessarily need to repeat their childhood immunizations once they are in remission. However, the timing and need for vaccinations may be
individualized based on the child's specific circumstances and immune status. This statement does not demonstrate a clear understanding of the teaching.
Correct Answer is C
Explanation
A. Hypertension is not a typical finding in severe dehydration. In fact, dehydration often leads to decreased blood pressure.
B. Increased urine output is not a typical finding in severe dehydration. Dehydration leads to decreased urine output as the body tries to conserve fluids.
C. This is the correct answer. In severe dehydration, the body compensates by increasing the respiratory rate to try to maintain oxygen levels and remove excess carbon dioxide. This is a compensatory mechanism in response to metabolic acidosis, which can occur with dehydration.
D. A capillary refill of 2 seconds indicates normal perfusion. In severe dehydration, capillary refill may be prolonged, indicating poor perfusion.
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