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.
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Related Questions
Correct Answer is D
Explanation
A. Tremors are not a typical clinical manifestation of heart failure. They may be associated with conditions like hyperthyroidism or certain medications.
B. Bradycardia (slow heart rate) is not a typical finding in heart failure. In fact, tachycardia (fast heart rate) is more commonly associated with this condition.
C. Increased appetite is not a typical clinical manifestation of heart failure. Children with heart failure may actually experience poor appetite due to decreased cardiac output.
D. Correct. Tachypnea (rapid breathing) is a common clinical manifestation of heart
failure. It can occur as the body tries to compensate for the decreased cardiac output by increasing respiratory rate in an effort to maintain oxygenation.
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.
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