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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. Wear clean cotton socks every day.
This is because cotton socks can help keep the feet dry and prevent infections. Wearing clean socks every day can also prevent blisters and injuries from friction.
Choice A is wrong because soaking feet twice daily can make the skin too soft and prone to injury. It can also wash away natural oils that protect the skin.
Choice C is wrong because rounding the edges of toenails when trimming can cause ingrown nails, which can lead to infection and pain. Toenails should be trimmed straight across and filed smooth.
Choice D is wrong because using moisturizing lotion between the toes can create a moist environment that promotes fungal growth. Moisturizing lotion should be applied to the rest of the feet, but not between the toes.
Some other foot care guidelines for people with diabetes are:
- Inspect your feet daily and look for signs of injury, such as scrapes, cuts, blisters, etc.
- Wash your feet every day in warm water with mild soap.
Hot water and harsh soaps can damage your skin. Check the water temperature with your fingers or elbow before putting your feet in.
- Don’t walk barefoot.
Protect your feet from heat and cold. Wear appropriate fitting shoes to avoid injury and blisters.
- See a doctor to remove corns or calluses (don’t do it yourself). Don’t use chemical wart removers, razor blades, corn plasters, or liquid corn or callus removers.
- Don’t sit with your legs crossed or stand in one position for long periods of time.
- See your doctor regularly for foot exams and report any problems or changes in your feet.
References:
Correct Answer is B
Explanation
The correct answer is choiceb. Instruct the client to notify the provider if diarrhea develops.
Choice A rationale:
Infusing penicillin G over 10 minutes is not recommended as it may cause adverse reactions.The infusion rate should be based on the specific guidelines for the medication and patient condition.
Choice B rationale:
Diarrhea can be a sign of a serious side effect called Clostridium difficile-associated diarrhea, which can occur with antibiotic use.It is important for the client to notify the provider if this symptom develops.
Choice C rationale:
Penicillin G should be stored according to the manufacturer’s instructions, which typically do not include refrigeration after reconstitution.Incorrect storage can affect the medication’s efficacy.
Choice D rationale:
Checking for a sulfa allergy is not relevant for penicillin G administration.Sulfa allergies are related to sulfonamide antibiotics, not penicillins.
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