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
Administering vaccines prior to discharge is not recommended for a child with neutropenia because their immune system is compromised. Vaccines, especially live vaccines, can pose a risk of infection in immunocompromised individuals.
Choice B rationale
Obtaining the child’s rectal temperature once daily is not advisable for a child with neutropenia. Rectal thermometers can cause mucosal injury and increase the risk of infection in neutropenic patients.
Choice C rationale
Avoiding raw fruits and vegetables in the child’s diet is crucial for a child with neutropenia. Raw fruits and vegetables can harbor bacteria and other pathogens that can cause infections in immunocompromised individuals.
Choice D rationale
Bathing the child every other day is not sufficient for maintaining hygiene in a child with neutropenia. Daily bathing is recommended to reduce the risk of infection by removing potential pathogens from the skin.
Correct Answer is B
Explanation
Choice A rationale
Increased throat pain is common after a tonsillectomy and can be managed with pain relief measures. It is not the most critical finding.
Choice B rationale
Frequent swallowing can indicate bleeding at the surgical site, which is a serious complication that requires immediate attention.
Choice C rationale
Refusal to drink clear liquids is concerning for dehydration but is not as immediately critical as signs of bleeding.
Choice D rationale
Crying often can be due to pain or discomfort but is not as critical as signs of bleeding.