A nurse is caring for a child in the PACU following a tonsillectomy.
Which of the following finding requires immediate intervention by the nurse should the nurse?
Dark brown blood noted in emesis
Frequent swallowing
Axillary temperature of 38 C (100 f)
Child reports pain level of 5 on the FACES scale
The Correct Answer is B
The correct answer is choice B.
Choice A rationale:
Dark brown blood in emesis is typically old blood and may not require immediate intervention. However, it should still be monitored and reported to the healthcare provider.
Choice B rationale:
Frequent swallowing can indicate active bleeding from the surgical site, which requires immediate intervention. This is a sign that the child may be swallowing blood, which can lead to significant blood loss.
Choice C rationale:
An axillary temperature of 38°C (100°F) is a mild fever and not uncommon postoperatively. It should be monitored, but it does not require immediate intervention.
Choice D rationale:
A pain level of 5 on the FACES scale indicates moderate pain, which is expected after a tonsillectomy. Pain management should be addressed, but it does not require immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is C.
Choice A reason: A White Blood Cell (WBC) count of 20,000/mm³ is significantly higher than the normal range for children, which is typically between 5,000 to 10,000/mm³. In the context of acute lymphoblastic leukemia (ALL), a high WBC count could indicate an active disease process or a reaction to treatment, rather than a therapeutic effect.
Choice B reason: A hemoglobin level of 5.5 g/dL is quite low, as the normal range for children is generally between 11 to 16 g/dL. This level of hemoglobin suggests anemia, which is a common condition in patients with leukemia due to the disease itself or as a side effect of chemotherapy. It does not necessarily indicate that the treatment is having a therapeutic effect.
Choice C reason: A Platelet count of 150,000/mm³ is within the lower end of the normal range for children, which is approximately 150,000 to 450,000/mm³. This can be considered a sign that the treatment is working effectively, as it indicates bone marrow recovery and the production of platelets is returning to normal levels.
Choice D reason: A Red Blood Cell (RBC) count of 3/mm³ is extremely low. The normal range for children’s RBC count is about 4 million to 5.5 million/mm³. Such a low RBC count would indicate severe anemia and is not a sign of effective treatment for ALL.
Correct Answer is {"xRanges":[313.765625,383.765625],"yRanges":[279.609375,349.609375]}
Explanation
Choice B rationale
Patent ductus arteriosus (PDA) is a condition where the opening between the two major blood vessels leading from the heart fails to close after birth. In the womb, this opening, known as the ductus arteriosus, is a normal part of the baby’s circulatory system. It usually closes shortly after birth. If it remains open, it’s called a patent ductus arteriosus.
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