A 5-year-old child is on the pediatric unit 6 hours post-op for a tonsillectomy. He is spitting up clear mucus and refusing to drink because his throat hurts. What should be the priority nursing action?
Notify the physician regarding the risk of dehydration.
Medicate the child with Tylenol with Codeine as ordered for pain.
Offer the child cherry popsicles to encourage fluid intake.
Assess the operative site for post-op bleeding.
The Correct Answer is D
Choice A reason: This response is not the priority action because dehydration is not an immediate threat to the child's life. The nurse should first rule out any signs of hemorrhage, which is a common complication of tonsillectomy.
Choice B reason: This response is not the priority action because pain medication may mask the symptoms of bleeding, such as increased swallowing or restlessness. The nurse should first assess the child for any signs of hemorrhage, and then administer pain medication as needed.
Choice C reason: This response is not the priority action because cherry popsicles may irritate the throat and cause bleeding. The nurse should first assess the child for any signs of hemorrhage, and then offer clear fluids or ice chips to the child.
Choice D reason: This response is the priority action because post-op bleeding is a serious and potentially fatal complication of tonsillectomy. The nurse should assess the operative site for any signs of bleeding, such as fresh blood, clots, or increased swallowing. The nurse should also monitor the child's vital signs, oxygen saturation, and level of consciousness. If bleeding is suspected, the nurse should notify the physician immediately and prepare for emergency interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: 0 - This would indicate that the child shows no signs of discomfort or pain. However, the nurse observed an occasional grimace and squirming, tense activity, which are signs of mild discomfort.
Choice B:Choice B is incorrect because it only accounts for one of the two behavioral deviations noted by the nurse. Scoring a 1 would mean only one category, such as the facial expression, received a point while all others remained at 0. Since both face and activity were abnormal, this score is too low.
Choice C: This is correct because the FLACC scale assigns points based on specific behaviors. The "Face" assessment of an occasional grimace earns 1 point. The "Activity" assessment of squirming and tension earns another 1 point. With legs, cry, and consolability all scored at 0, the cumulative total for the patient is 2.
Choice D: 3 - A score of 3 would suggest even more significant signs of discomfort or pain, which is not consistent with the nurse's observations.
Correct Answer is A
Explanation
Choice A reason: This is correct because the ordered dose of Amoxicillin is within the safe range for a 3-year-old weighing 14 kg. The daily dose of Amoxicillin is 175 mg x 3 = 525 mg. The safe dose range for a 14 kg child is 20-40 mg/kg/day, which is 280-560 mg/day. Therefore, the ordered dose is safe.
Choice B reason: This is incorrect because the ordered dose of Amoxicillin is not above the safe range for a 3-year-old weighing 14 kg. It is not necessary to reduce the dose or report it to the prescriber.
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