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 C
Explanation
Choice A rationale
A hemoglobin level of 6.8 g/dL is significantly lower than the normal range (9.5 to 14 g/dL) and indicates anemia. This finding does not suggest that the treatment for acute lymphoblastic leukemia is having a therapeutic effect.
Choice B rationale
An RBC count of 5/mm³ is within the normal range (4 to 5.5/mm³) but does not specifically indicate that the treatment for acute lymphoblastic leukemia is having a therapeutic effect.
Choice C rationale
A WBC count of 15,000/mm³ is higher than the normal range (5,000 to 10,000/mm³) but can indicate that the treatment is having a therapeutic effect. In the context of acute lymphoblastic leukemia, an elevated WBC count can be a sign that the body is responding to treatment.
Choice D rationale
A platelet count of 98,000/mm³ is lower than the normal range (150,000 to 400,000/mm³) and does not indicate that the treatment for acute lymphoblastic leukemia is having a therapeutic effect.
Correct Answer is B
Explanation
Choice A rationale
An increase in potassium levels is not an indicator of the effectiveness of furosemide, which is a diuretic used to reduce fluid overload.
Choice B rationale
A decrease in peripheral edema indicates that furosemide is effectively reducing fluid retention in the body.
Choice C rationale
A decrease in cardiac output is not a desired effect of furosemide and may indicate worsening heart function.
Choice D rationale
An increase in venous pressure is not an indicator of the effectiveness of furosemide and may suggest fluid overload.