A nurse is caring for a child who is postoperative following a tonsillectomy.

Which of the following findings indicates that the child may be experiencing hemorrhage?

Elevated pain level.

Increased drowsiness.

Frequent swallowing.

Diminished breath sounds.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C, frequent swallowing.

This indicates that the child may be experiencing hemorrhage because they are trying to clear the blood from their throat. Frequent swallowing is one of the initial signs of bleeding immediately after tonsillectomy.

Choice A is wrong because elevated pain level is not a specific sign of hemorrhage.

Pain is expected after a tonsillectomy and can be managed with medication and fluids.

Choice B is wrong because increased drowsiness is not a specific sign of hemorrhage.

Drowsiness can be caused by anesthesia, medication, or dehydration.

Choice D is wrong because diminished breath sounds are not a specific sign of hemorrhage.

Diminished breath sounds can be caused by respiratory infection, asthma, or bronchospasm.

Normal ranges for hemoglobin and hematocrit are 11.5 to 15.5 g/dL and 34 to 45% for children, respectively.

Normal ranges for platelet count are 150,000 to 450,000/mm3 for both children and adults.

Normal ranges for plasma clotting variables depend on the specific test and method used.

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Correct Answer is B

Explanation

The correct answer is choice B. Apply direct pressure to the puncture site.

Choice A rationale:

Applying intermittent pressure 2.5 cm (1 inch) below the percutaneous skin site is not the best approach. This method may not effectively control the bleeding and could potentially dislodge the introducer sheath.

Choice B rationale:

Applying direct pressure to the puncture site is the most effective way to control bleeding. Direct pressure helps to promote clot formation and reduce blood flow to the area, which is crucial in managing postoperative bleeding.

Choice C rationale:

Elevating the affected extremity above the level of the heart is not appropriate in this situation. While elevation can reduce swelling, it does not address the immediate need to control active bleeding.

Choice D rationale:

Leaving the dressing undisturbed and notifying the physician immediately is not advisable. Immediate action to control the bleeding is necessary before notifying the physician. Delaying intervention could lead to significant blood loss.

A. Epistaxis B. Headache C. Dizziness D. Shortness of breath

Correct Answer is C

Explanation

, dizziness.

Dizziness is a manifestation of hypovolemia, which is a decrease in blood volume due to fluid loss.

Hypovolemia can cause orthostatic hypotension, which is a drop in blood pressure when changing positions. This can lead to dizziness, lightheadedness, or fainting.

Choice A, epistaxis, is wrong because it is not a sign of hypovolemia, but rather a possible cause of it. Epistaxis is a nosebleed that can result from trauma, infection, dryness, or coagulation disorders.

Choice B, headache, is wrong because it is not a specific sign of hypovolemia, but rather a nonspecific symptom that can have many causes. Headache can be associated with dehydration, but it can also be caused by stress, infection, inflammation, or other factors.

Choice D, shortness of breath, is wrong because it is not a sign of hypovolemia, but rather a sign of fluid volume excess.

Fluid volume excess is an increase in blood volume due to fluid retention or overload. Fluid volume excess can cause dyspnea, which is difficulty breathing or shortness of breath.

Normal ranges for blood pressure are 90/60 mm Hg to 120/80 mm Hg for adults.

Normal ranges for heart rate are 60 to 100 beats per minute for adults.

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A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following findings indicates that the child may be experiencing hemorrhage?

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A nurse is caring for a child who is postoperative following a tonsillectomy.

Which of the following findings indicates that the child may be experiencing hemorrhage?