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 D
Explanation
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.
Correct Answer is ["D","E"]
Explanation
A. Maintaining the child in a supine position is not recommended after a tonsillectomy.
The child should be positioned on their side to prevent aspiration.
B. Cranberry juice is acidic and may be irritating to the surgical site. Clear, non-acidic fluids are usually recommended after a tonsillectomy.
C. While coughing should be minimized to prevent irritation to the surgical site, the child should not be discouraged from coughing if needed to clear secretions.
D. Administering an analgesic on a scheduled basis is important for managing pain after a tonsillectomy. This helps to maintain a consistent level of pain control.
E. Observing the child for frequent swallowing is important, as it may indicate bleeding or discomfort. This is a key assessment after a tonsillectomy.
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