A nurse is caring for a 5-year-old child following a tonsillectomy and adenoidectomy. Which of the following findings should the nurse identify as an indication of hemorrhage?
Continuous swallowing.
Blood pressure 95/56 mm Hg.
Heart rate 54/min.
Flushing of the face.
The Correct Answer is A
Choice A rationale
Continuous swallowing can be an indication of hemorrhage following a tonsillectomy and adenoidectomy. This is because the child may be swallowing blood that is coming from the surgical site.
Choice B rationale
Blood pressure of 95/56 mm Hg is within the normal range for a 5-year-old child and does not specifically indicate hemorrhage.
Choice C rationale
A heart rate of 54/min is lower than the normal range for a 5-year-old child and may indicate bradycardia, but it is not a specific sign of hemorrhage.
Choice D rationale
Flushing of the face is not a specific sign of hemorrhage. It may indicate other conditions but is not typically associated with bleeding following a tonsillectomy and adenoidectomy.
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Correct Answer is A
Explanation
Choice A rationale
Keeping electrical wires hidden from view is essential to prevent toddlers from pulling on them, which can lead to electrical burns or other injuries. It is a proactive measure to ensure a safe environment for children who are naturally curious and prone to exploring with their hands.
Choice B rationale
Encouraging outdoor activities between the hours of 1100 and 1300 can expose toddlers to the sun’s peak intensity, increasing the risk of sunburn. It is safer to encourage outdoor activities outside these hours when the sun is less intense.
Choice C rationale
Setting the water heater to 60°C (140°F) is too high and poses a scalding risk. The recommended temperature to prevent burns is 49°C (120°F), which is hot enough for household use but not so hot as to cause immediate burns upon contact.
Choice D rationale
Turning pot handles toward the front of the stove is dangerous as it increases the risk of toddlers reaching up and pulling hot contents onto themselves. The correct practice is to turn pot handles toward the back of the stove to keep them out of reach of children.
Correct Answer is A
Explanation
Choice A rationale
The first voided specimen is discarded to ensure that the 24-hour urine collection starts with an empty bladder and accurately reflects the urine produced over the entire period.
Choice B rationale
Voiding every hour is not necessary and may not be practical for a 24-hour urine collection.
Choice C rationale
The final specimen should be included in the same container as the rest of the 24-hour urine collection.
Choice D rationale
Cleansing the perineum with a povidone-iodine solution is not required for a 24-hour urine collection.