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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?

A.

Dark brown blood noted in emesis

B.

Axillary temperature 38° C (100° F)

C.

Child reports pain level of 5 on the FACES scale

D.

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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Related Questions

Correct Answer is A

Explanation

A. Hyperpyrexia, or extremely high fever, is a potential complication of acute
acetylsalicylic acid (aspirin) poisoning. It can occur due to the toxic effects of salicylates on the hypothalamus, which regulates body temperature.

B. Polyuria (excessive urination) is not a typical finding associated with acute acetylsalicylic acid poisoning.

C. Jaundice (yellowing of the skin and eyes) is not a typical finding associated with acute acetylsalicylic acid poisoning.

D. Neck vein distention is not a typical finding associated with acute acetylsalicylic acid poisoning. It may be a sign of increased central venous pressure, which is not directly related to salicylate toxicity.

Correct Answer is A

Explanation

A. Toddlers with a history of lead poisoning are at risk for developmental delays.
Developmental testing can help identify any delays that may require intervention or support.

B. Lead absorption is not related to iron intake. However, a diet rich in iron can help reduce the absorption of lead.

C. Blood testing, not stool testing, is the primary method for assessing lead levels. Blood lead levels provide the most accurate information about lead exposure.

D. While lead poisoning can cause changes in skin color in severe cases, it is not the primary assessment for lead exposure. Blood lead levels and developmental testing are more indicative of lead poisoning.

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