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 B
Explanation
A. Pinpoint pupils are a characteristic sign of opioid overdose, not inhalation of gasoline.
B. Correct. Ataxia (lack of coordination) can be a neurological symptom associated with inhalation of gasoline or other volatile substances. These substances can affect the central nervous system and lead to impaired coordination.
C. Hyperactive reflexes are not a typical finding associated with inhalation of gasoline.
This is more characteristic of conditions like hyperthyroidism or certain neurological disorders.
D. Hypothermia is not a typical finding associated with inhalation of gasoline. It is more likely to cause symptoms related to the central nervous system and respiratory system.
Correct Answer is C
Explanation
A. Assisting the child into a supine position is contraindicated in acute epiglottitis. This can lead to airway obstruction. The child should be allowed to assume a position of comfort, which is typically sitting up and leaning forward.
B. While obtaining a throat culture may be indicated for diagnostic purposes, it is not the first priority in the care of a child with acute epiglottitis. The immediate concern is ensuring airway patency and providing appropriate respiratory support.
C. This is the correct action. Acute epiglottitis is a potentially life-threatening condition that can rapidly lead to airway obstruction. Initiating droplet isolation precautions helps protect healthcare providers and other patients from potential transmission of the causative organism (often Haemophilus influenzae type B).
D. Checking oxygen saturation every 4 hours is important for monitoring respiratory status, but in the case of acute epiglottitis, continuous monitoring of oxygen saturation is often necessary due to the risk of sudden airway obstruction. This action does not address the immediate priority of ensuring a patent airway.
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