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 D
Explanation
Choice A rationale
A digoxin level of 1.2 ng/mL is within the therapeutic range (0.8 to 2 ng/mL) for toddlers receiving digoxin therapy. This level does not require a revision of the plan of care.
Choice B rationale
An apical pulse of 100/min is within the normal range for toddlers. Digoxin therapy requires monitoring of the heart rate, but this pulse rate does not necessitate a change in the plan of care.
Choice C rationale
A potassium level of 4.0 mEq/L is within the normal range (3.4 to 4.7 mEq/L) for toddlers. This electrolyte level does not require a revision of the plan of care.
Choice D rationale
Vomiting is a potential sign of digoxin toxicity. A toddler who has vomited 2 times in the last hour may be experiencing digoxin toxicity, and the plan of care should be revised to address this issue.
Correct Answer is A
Explanation
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.