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 A
A. Dark brown blood noted in emesis is a concerning finding and may indicate active bleeding. This requires immediate intervention by the nurse, as post-tonsillectomy hemorrhage is a potential complication.
B. An axillary temperature of 38° C (100° F) is slightly elevated, but it is not the most concerning finding in this situation. It may be expected after surgery due to inflammation and the body's stress response.
C. A pain level of 5 on the FACES scale indicates moderate pain. While pain management is important, it is not the most urgent concern in this situation.
D. Frequent swallowing may be expected after a tonsillectomy due to postoperative
throat discomfort. It is important to monitor for bleeding, but dark brown blood in emesis is a more immediate concern.
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Related Questions
Correct Answer is C
Explanation
A. Placing the child in the Trendelenburg position is not necessary for tracheostomy care. In fact, this position is generally not recommended for routine tracheostomy care.
B. Sterile technique, not clean technique, should be used when changing the tracheostomy tube to reduce the risk of infection.
C. This is the correct action. Having the child flex his head can help prevent tension on the tracheostomy ties and ensure a secure and comfortable fit.
D. Full-strength hydrogen peroxide is too harsh and can cause irritation to the skin around the stoma. It is recommended to use normal saline or a mild soap and water solution for cleaning.
Correct Answer is B
Explanation
A. A child with impetigo has a contagious skin infection. It would not be appropriate to room them with a preschooler who has just had surgery, as this could increase the risk of post-operative infection.
B. Correct. A child with a fractured left femur does not have a contagious condition that would pose a risk to the preschooler following Wilms' tumor removal. This would be an appropriate roommate.
C. A child with viral pneumonia has a contagious respiratory infection. This could put the preschooler at risk of developing a respiratory infection, which could be especially dangerous after surgery.
D. A child with cellulitis of the right radius has a contagious skin infection. It would not be appropriate to room them with a preschooler who has just had surgery, as this could increase the risk of post-operative infection.
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