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
Restraint prescriptions should be renewed every 24 hours, not 48 hours, to ensure the child’s safety and necessity of restraints.
Choice B rationale
Restraints should never be tied to the side rails as this can cause injury. They should be tied to the bed frame.
Choice C rationale
Quick-release knots are recommended for restraints to ensure they can be removed quickly in an emergency.
Choice D rationale
The child should be assessed more frequently than every 4 hours, typically every 2 hours, to ensure their safety and comfort.
Correct Answer is D
Explanation
Choice A rationale
Encouraging flexion and extension of the neck is contraindicated for a client with a halo vest as it can compromise the stability of the cervical spine.
Choice B rationale
Assessing the pin sites for infection once every other day is not sufficient. Pin sites should be assessed at least once per shift to detect and manage any potential infections early.
Choice C rationale
Tightening the screws on the halo device one-quarter turn every 48 hours is not recommended. Adjustments to the halo device should only be made by a healthcare provider to ensure the integrity of the device and the stability of the cervical spine.
Choice D rationale
Repositioning the client using a turning sheet is the correct action. This method helps to reposition the client safely without exerting unnecessary pressure on the cervical spine and aids in preventing pressure ulcers.