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 B
Explanation
Choice A rationale
Bacterial vaginosis and trichomoniasis are both sexually transmitted infections, but they are not nationally notifiable, meaning cases are not required to be reported to the Centers for Disease Control and Prevention.
Choice B rationale
Gonorrhea is a nationally notifiable sexually transmitted infection. This means that confirmed and probable cases are required to be reported to the Centers for Disease Control and Prevention.
Choice C rationale
Human Papilloma Virus (HPV) is a common sexually transmitted infection, but it is not nationally notifiable.
Choice D rationale
Genital Herpes Simplex Virus is a common sexually transmitted infection, but it is not nationally notifiable.
Correct Answer is A
Explanation
Choice A rationale
A preschool-age child being curious about what happened to the sibling’s body is an age-appropriate response to death. At this age, children often view death as temporary or reversible, and they may be curious about the physical realities of death.
Choice B rationale
A preschool-age child feeling responsible for the sibling’s death is not an age-appropriate response to death. While children at this age may sometimes believe their thoughts or actions can influence events, it’s not typical for them to feel personally responsible for a death.
Choice C rationale
A preschool-age child being able to give a logical explanation for the sibling’s death is not an age-appropriate response to death. Preschoolers typically have a limited understanding of the causes and permanence of death.
Choice D rationale
A preschool-age child viewing the sibling’s death as permanent is not an age-appropriate response to death. Most children in this age group do not understand that death is permanent.
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