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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Changing positions frequently may be distracting and confusing for the child. It is important to find a comfortable and quiet environment for communication.
B. Exaggerating the pronunciation of words may distort the natural flow of speech and make it more difficult for the child to understand. It is best to speak clearly and at a normal pace.
C. Using light touch when initiating conversation is not effective for a child with hearing loss, as they rely primarily on visual and auditory cues for communication.
D. This is the correct action. Maintaining a neutral facial expression allows the child to observe facial cues and expressions that are important for understanding non-verbal communication. It also helps create a comfortable and natural environment for conversation.
Correct Answer is ["2.2"]
Explanation
To calculate the dose of ondansetron for a child who is receiving chemotherapy, the nurse needs to use the following formula:
Dose (mL) = (Dose ordered in mg / Dose available in mg) x Volume available in mL
In this case, the dose ordered in mg is 0.15 mg/kg x 29.4 kg, which equals 4.41 mg. The dose available in mg is 4 mg, and the volume available in mL is 2 mL. Therefore, the dose in mL is:
Dose (mL) = (4.41 mg / 4 mg) x 2 mL Dose (mL) = 2.205 mL
The nurse should round the answer to the nearest tenth, so the final answer is 2.2 mL. The nurse should administer 2.2 mL of ondansetron IV to the child who is receiving chemotherapy.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.