A nurse is caring for a 6-year-old male client in the post-anesthesia care unit (PACU).
Which findings indicate that the client may be experiencing a complication following the tonsillectomy?Select all that apply.
Blood pressure 105/64 mm Hg
Heart rate 124/min
One small emesis with dark brown blood
Throat pain rated as 8 on a scale of 0 to 10
Frequent throat clearing and swallowing
Temperature 37°C (98.6°F)
Restlessness
Correct Answer : B,E,G
Choice A rationale: A blood pressure of 105/64 mm Hg is within the normal range for a 6-year-old child and does not indicate a complication. Hypotension would be a concern if there were significant blood loss, but this value does not suggest hemodynamic instability. Therefore, this finding is not indicative of a post-tonsillectomy complication.
Choice B rationale: A heart rate of 124/min is elevated compared to the earlier reading of 115/min and may indicate distress or compensatory tachycardia due to pain or bleeding. Increased heart rate can be an early sign of hemorrhage, which is a known complication following tonsillectomy. Monitoring for further changes is critical.
Choice C rationale: One small emesis with dark brown blood is not necessarily abnormal after tonsillectomy, as it may represent swallowed blood from the surgical site. Bright red blood or repeated emesis would be more concerning for active bleeding. This finding alone does not confirm a complication.
Choice D rationale: Throat pain rated as 8/10 is expected following tonsillectomy and does not necessarily indicate a complication. Pain management is essential, but this finding alone does not suggest an abnormal postoperative course.
Choice E rationale: Frequent throat clearing and swallowing are concerning signs that may indicate active bleeding at the surgical site. These behaviors suggest the child is attempting to manage secretions, which could include blood. This finding warrants immediate evaluation to rule out hemorrhage.
Choice F rationale: A temperature of 37°C (98.6°F) is normal and does not indicate infection or other complications. Fever would be a more concerning sign of infection or systemic response.
Choice G rationale: Restlessness is a nonspecific but concerning sign that may indicate discomfort, pain, or distress due to bleeding. Combined with other findings, such as frequent swallowing and tachycardia, restlessness supports the possibility of a complication requiring further assessment
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Steatorrhea is the presence of excess fat in the stools, resulting in bulky, foul-smelling, and often floating feces. It is a sign of malabsorption and is commonly associated with conditions like celiac disease or cystic fibrosis. It is not a characteristic sign of a urinary tract infection (UTI), which is an infection of the urinary system, not the gastrointestinal tract.
Choice B rationale
Jaundice is a yellow discoloration of the skin and mucous membranes caused by an elevated level of bilirubin in the blood. It is a sign of liver disease or increased red blood cell destruction and is not associated with a urinary tract infection (UTI). A UTI primarily affects the urinary system and presents with genitourinary symptoms.
Choice C rationale
Incontinence, or loss of bladder control, is a common and often the first sign of a urinary tract infection (UTI) in a toilet-trained toddler. The inflammation and irritation of the bladder (cystitis) and urethra due to the bacterial infection can lead to bladder spasms, urgency, and an inability to control urination, resulting in accidents.
Choice D rationale
Rebound tenderness is a clinical sign of peritonitis, which is the inflammation of the peritoneum, the membrane lining the abdominal cavity. It is a sign of a serious abdominal condition such as appendicitis. It is not typically associated with a urinary tract infection (UTI), which is a localized infection of the urinary system.
Correct Answer is C
Explanation
Choice A rationale
Reinserting tympanoplasty tubes can introduce bacteria into the middle ear, increasing the risk of infection, such as otitis media. The tympanic membrane, a delicate structure, could also be damaged during the process, leading to perforation or scarring. Proper placement requires a sterile environment and specialized instruments, which are not available outside a clinical setting.
Choice B rationale
An immediate trip to the emergency department is not usually necessary unless the child is experiencing other symptoms, such as severe pain, fever, or signs of a serious ear infection. The absence of the tube is not considered a medical emergency on its own, so a scheduled appointment with a provider is more appropriate.
Choice C rationale
When a tympanoplasty tube falls out, notifying the provider is the correct course of action because it allows for proper assessment. The provider can determine if a new tube is necessary or if the underlying condition, often recurrent ear infections, has resolved. They will schedule a follow-up appointment to check the integrity of the eardrum and the child's overall health, ensuring appropriate next steps.
Choice D rationale
Tympanoplasty tubes are not sutured in place and are designed to naturally extrude from the ear canal over time. They are meant to remain in place for several months to a year, providing ventilation and drainage to the middle ear. The provider's office is the appropriate place for reevaluation, not a surgical suite.
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