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 D
Explanation
A. The cream should be removed after it has been on the skin for the recommended amount of time. It is typically wiped off before the procedure.
B. The medication should applied repeatedly to provide analgesia
C. Washing the site with alcohol before applying the cream is not necessary and may cause unnecessary skin irritation.
D. Lidocaine and prilocaine cream typically require about 60 minutes to take effect.
Correct Answer is C
Explanation
A. Placing the child in a supine position is not the appropriate position for a lumbar puncture. The child should be in a lateral position.
B. A semi-Fowler's position is not the appropriate position for a lumbar puncture. The child should be in a lateral position.
C. Correct. Placing the child in a lateral position allows for better access to the spinal canal, which is necessary for a lumbar puncture.
D. Placing the child in a prone position is not the appropriate position for a lumbar puncture. The child should be in a lateral position.
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