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
Offering a prize for not crying can create undue pressure and anxiety for the child.
Choice B rationale
Telling the child the medicine will fix them can be misleading and does not provide accurate information about the procedure.
Choice C rationale
Allowing the child to choose which leg to receive the injection in gives them a sense of control and can reduce anxiety.
Choice D rationale
Telling the child they will only feel a little stick can be misleading and may not adequately prepare them for the discomfort.
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.