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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: A consistent growth pattern on the 25th percentile is not an indicator of child abuse. It means that the child is growing normally and is within the expected range for their age and gender.

Choice B reason: A contusion on the child's leg is not necessarily an indicator of child abuse. It could be a result of accidental injury or normal play. However, the nurse should assess the location, size, shape, and color of the bruise, and compare it with the parents' explanation.

Choice C reason: Fearful behavior when the nurse enters the room is not a specific indicator of child abuse. It could be a sign of anxiety, shyness, or discomfort in an unfamiliar setting. The nurse should try to establish rapport with the child and use developmentally appropriate communication techniques.

Choice D reason: An inconsistent story on the child's injury is a strong indicator of child abuse. It suggests that the parents are trying to hide or cover up the cause of the injury, or that they are not aware of how the injury occurred. The nurse should document the discrepancies and report any suspicions of abuse to the appropriate authorities.

A. Fidelity B. Equality C. Autonomy D. Justice

Correct Answer is C

Explanation

Choice A reason: Fidelity is the principle of being faithful and loyal to one's commitments and obligations. It is not directly related to the situation, although the nurse may have a duty to respect the parent's wishes.

Choice B reason: Equality is the principle of treating everyone fairly and impartially. It is not relevant to the situation, as there is no issue of discrimination or favoritism involved.

Choice C reason: Autonomy is the principle of respecting the right of individuals to make their own decisions. It is the most applicable to the situation, as the nurse recognizes the parent's authority to decide what is best for their child.

Choice D reason: Justice is the principle of distributing benefits and burdens equitably and according to valid criteria. It is not pertinent to the situation, as there is no conflict of interest or allocation of resources involved.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When obtaining a history from parents of a 4-year-old child, what indicator should prompt the nurse to consider suspected child abuse?

Correct Answer is D

Explanation

Shortly before a child's elective surgery, the parent tells the nurse, "I am having second thoughts about my child undergoing this surgery." The nurse respects the parent's concern and calls the surgeon. What ethical/moral principle is represented by this situation?

Correct Answer is C

Explanation

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