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
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.
Correct Answer is B
Explanation
Choice A rationale
Blood should not be stored at room temperature for more than 30 minutes. The second unit should be stored in a blood bank refrigerator until needed.
Choice B rationale
Each unit of blood should be infused within 4 hours to reduce the risk of bacterial contamination.
Choice C rationale
RBCs should be administered using filtered IV tubing to prevent the infusion of clots and other debris.
Choice D rationale
Dextrose 5% in water should not be used during the infusion of packed RBCs as it can cause hemolysis.