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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Blood urea nitrogen (BUN) of 12 mg/dL is within the normal range for a child.
B. Blood urea nitrogen (BUN) of 6 mg/dL is within the normal range for a child.
C. A creatinine level of 1.4 mg/dL is elevated and may indicate impaired kidney function.
This value should be reported to the provider, especially in the context of gentamicin administration, as gentamicin can be nephrotoxic.
D. Creatinine level of 0.3 mg/dL is within the normal range for a child.
Correct Answer is D
Explanation
A. Toddlers with phenylketonuria (PKU) need to limit their intake of phenylalanine, an amino acid found in protein. Therefore, the toddler's protein consumption should be carefully controlled and monitored.
B. Foods high in iron do not need to be specifically limited for a child with PKU. Iron-rich foods are important for overall health and should be included in the diet.
C. Aspartame contains phenylalanine and should be avoided by individuals with PKU. PKU is a metabolic disorder that impairs the body's ability to break down phenylalanine, so it is important to limit phenylalanine intake.
D. This is correct. Foods containing milk products should be avoided, as they are a source of phenylalanine and can contribute to an excessive intake of this amino acid in a child with PKU. Instead, specialized medical foods low in phenylalanine are recommended.
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