A nurse is caring for a child in the PACU following a tonsillectomy. Which of the following findings requires immediate intervention by the nurse?
Dark brown blood noted in emesis
Axillary temperature 38° C (100° F)
Child reports pain level of 5 on the FACES scale
Frequent swallowing
The Correct Answer is D
A. Dark brown blood in emesis is expected postoperatively due to swallowed blood and does not require immediate intervention.
B. A mild fever (38°C or 100°F) can occur postoperatively and is not an emergency.
C. Pain is expected after a tonsillectomy and should be managed but does not require immediate intervention.
D. Frequent swallowing may indicate active bleeding from the surgical site, which requires immediate assessment and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "You should notify your provider if your testes are firm and egg shaped." This statement does not provide specific guidance on when or how to perform the examination. It also describes a normal shape of the testes.
B. This is the correct statement. Performing the testicular self-examination following a warm shower helps relax the scrotal tissue, making it easier to detect any abnormalities or changes.
C. "If you feel a hard lump, wait 1 month and retest yourself." This is not advisable. If a hard lump is detected during a testicular self-examination, the individual should promptly notify their healthcare provider for further evaluation.
D. "You should perform the examination once every other month." While regular
testicular self-examinations are important, it is generally recommended to perform them monthly, not once every other month.
Correct Answer is B
Explanation
A. Eating a large amount of food one day and very little the next is a normal eating pattern for toddlers. They may have days when they eat more and days when they eat less.
B. This finding should be reported to the provider. Breath-holding spells during temper tantrums can be concerning and may require further evaluation.
C. Toddlers typically need about 11-14 hours of sleep per day, so sleeping 11 to 12 hours is within the normal range.
D. A vocabulary of 30 words is considered normal for a 24-month-old toddler.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.