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 C
Explanation
A. Drinking milk on an empty stomach is not recommended for individuals with lactose intolerance, as it can lead to more pronounced symptoms.
B. Flavored yogurts may contain additional sugars or additives that can exacerbate
symptoms in individuals with lactose intolerance. It is generally recommended to choose plain, unsweetened yogurt.
C. This is a correct instruction. There are various nondairy sources of calcium, such as fortified soy milk, almond milk, leafy green vegetables, and certain types of fish (like salmon and sardines).
D. Tolerability of plain milk versus flavored milk can vary from person to person. Some individuals may find one easier to tolerate than the other, but it is not a universal rule for everyone with lactose intolerance.
Correct Answer is A
Explanation
A. This is the correct intervention. Encouraging the toddler to use an incentive spirometer helps promote lung expansion and prevent atelectasis (collapsed lung tissue), which is
important for postoperative respiratory function.
B. Placing a cooling blanket on the toddler is not a standard intervention following routine surgery. It's important to monitor the toddler's temperature and use appropriate measures if they experience hyperthermia.
C. Administering IV dantrolene sodium is used for the treatment of malignant hyperthermia, a rare but life-threatening reaction to certain medications used during anesthesia. It is not a routine postoperative intervention.
D. Aspirin is generally not recommended for pain relief in children due to the risk of Reye's syndrome. Other pain management options, such as acetaminophen or ibuprofen, are typically used for postoperative pain in children.
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