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.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
The human papillomavirus (HPV) vaccine is not typically given at 12 months of age. It is usually administered to adolescents.
Choice B rationale
The inactivated polio virus vaccine is not typically given at 12 months of age. It is usually administered earlier in infancy.
Choice C rationale
The hepatitis B vaccine is not typically given at 12 months of age. It is usually administered shortly after birth and in the first few months of life.
Choice D rationale
The varicella vaccine, which protects against chickenpox, is typically given at 12 months of age.
Correct Answer is B
Explanation
Choice A rationale
Meperidine is not the first choice for pain management in sickle cell crisis due to its potential to cause seizures and other side effects.
Choice B rationale
Bed rest is recommended during a sickle cell crisis to decrease the body’s demand for oxygen, reduce the workload of the heart, and improve blood flow.
Choice C rationale
Limiting fluid intake is not recommended during a sickle cell crisis. Adequate hydration is important to prevent further sickling of cells and to maintain kidney function.
Choice D rationale
Cold compresses can cause vasoconstriction and may exacerbate the crisis. Warm compresses are usually recommended to increase blood flow and reduce pain.
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