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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Increased expectoration (coughing up mucus) indicates that the chest physiotherapy treatments have been effective in helping to clear the airways of mucus, which is a common goal in managing cystic fibrosis.

B. Increased urine output is not a direct indicator of the effectiveness of chest physiotherapy in managing cystic fibrosis.

C. Increased heart rate is not a specific indicator of the effectiveness of chest physiotherapy in managing cystic fibrosis. In fact, an increased heart rate may indicate stress or discomfort.

D. Reduced pain is a positive outcome but may not be directly related to the effectiveness of chest physiotherapy in managing cystic fibrosis. The primary goal of chest physiotherapy is to improve airway clearance.

A. "I should give my child water after giving the medication." B. "I should give the medication with foods that are high in fiber." C. "I should give my child another dose if he vomits right after taking the medication." D. "I should mix the medication with 4 ounces of my child's favorite juice."

Correct Answer is A

Explanation

A. This statement indicates understanding. Giving water after administering digoxin helps ensure that the medication is swallowed and reaches the stomach, which is important for proper absorption.
B. Giving digoxin with foods high in fiber is not a specific instruction for administering this medication. It is important to follow the healthcare provider's specific dosing
instructions.
C. If a child vomits after taking digoxin, the parent should not give another dose. They should wait until the next scheduled dose. Double dosing can lead to overdose.
D. Mixing digoxin with juice is not recommended, as it may affect the absorption of the medication. It is best to give digoxin with a small amount of water.

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A nurse is caring for a child in the PACU following a tonsillectomy. Which of the following findings requires immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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