Difficulty: Medium
Average Score: 65%
Simulated
Passage / Scenario
A child post-tonsillectomyA nurse is caring for a child in the PACU following a tonsillectomy. Which of the following finding requires immediate intervention by the nurse should the nurse?
Correct answer
B
Rationale
The correct answer is B: Frequent swallowing. This finding indicates potential post-tonsillectomy bleeding, a serious complication requiring immediate intervention. Swallowing may indicate blood pooling in the throat, leading to airway compromise. Dark brown blood in emesis (choice A) is expected post-operatively. An axillary temperature of 38 C (100 F) (choice C) can be due to surgical stress. Child reporting pain level of 5 (choice D) is manageable.