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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 D

Explanation

Choice A rationale

Odorless urine is not a specific indicator of effective treatment for acute poststreptococcal glomerulonephritis (APSGN)16.

Choice B rationale

A temperature of 37.2°C (99°F) is within the normal range and does not specifically indicate effective treatment for APSGN16.

Choice C rationale

No report of pain with voiding is not a specific indicator of effective treatment for APSGN16.

Choice D rationale

Clear urine indicates that the hematuria (blood in urine) has resolved, which is a sign of effective treatment for APSGN1617.

Correct Answer is B

Explanation

Choice A rationale

Performing the dressing change independently does not demonstrate effective collaboration. Effective collaboration involves working with other healthcare professionals to provide the best care for the patient. By performing the dressing change independently, the nurse is not utilizing the expertise and support of the healthcare team.

Choice B rationale

Seeking guidance from the wound care nurse demonstrates effective collaboration. The wound care nurse has specialized knowledge and skills in wound management, and seeking their guidance ensures that the patient receives the best possible care. This collaborative approach enhances patient outcomes and promotes a team-based approach to healthcare.

Choice C rationale

Asking another nurse to complete the dressing change does not demonstrate effective collaboration. While delegating tasks can be part of collaboration, it is important that the nurse seeks guidance from the appropriate specialist, in this case, the wound care nurse, to ensure the best care for the patient.

Choice D rationale

Consulting only the client’s family for assistance does not demonstrate effective collaboration. While involving the family in the care process is important, it is essential to collaborate with other healthcare professionals who have the expertise to provide the best care for the patient.

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