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","B","C"]
Explanation
A. Providing a high-calorie diet is important for a child with extensive burns to support wound healing and recovery.
B. Monitoring intake and output is crucial to assess fluid balance and ensure that the child is receiving enough fluids and nutrients for healing.
C. Changing dressings using an aseptic technique helps prevent infection, which is a significant risk in burn wounds.
D. Removing splints during sleep is not recommended, as they are in place to prevent contractures. They should be worn consistently, including during sleep.
E. Administering analgesics IM (intramuscularly) is not typically indicated. Pain
management can be achieved through various routes, and IM administration may not be necessary. Additionally, it's important to consider the child's pain level and choose the most appropriate and effective route for analgesia.
Correct Answer is A
Explanation
A. Applying warm compresses can help to improve blood flow and relieve pain in areas affected by a sickle cell crisis. This is a beneficial intervention.
B. Decreasing fluid intake is not recommended. Maintaining hydration is important in the management of sickle cell disease, as it helps to prevent dehydration and reduces the risk of sickling.
C. Furosemide is a diuretic and is not typically used in the treatment of a sickle cell crisis.
It is not an appropriate intervention in this situation.
D. Contact precautions are not necessary for a sickle cell crisis. This crisis is not a contagious condition. Standard precautions for infection control should be followed.
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