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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?

 

A.

Continuous swallowing.

B.

Blood pressure 95/56 mm Hg.

C.

Heart rate 54/min.

D.

Flushing of the face.

Answer and Explanation

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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View Related questions

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.

Correct Answer is A

Explanation

Choice A rationale

Bradypnea, or slow breathing, is a common and serious side effect of morphine, especially in children. It requires immediate attention.

Choice B rationale

Morphine does not typically affect wound healing. This is more associated with corticosteroids.

Choice C rationale

Morphine can cause hypotension, not hypertension.

Choice D rationale

Stevens-Johnson syndrome is a rare but severe reaction to medications, including some antibiotics and anticonvulsants, but not commonly associated with morphine.

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