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 ["A","B"]
Explanation
Choice A reason: This response is correct because antibiotics are indicated for bacterial pneumonia caused by staphylococcus. Antibiotics help to fight the infection and prevent complications.
Choice B reason: This response is correct because cluster care means grouping nursing interventions together to minimize the disruption of the child's rest and sleep. Cluster care helps to conserve the child's energy and promote healing.
Choice C reason: This response is not correct because fluids are essential for hydration and thinning of secretions in pneumonia. Fluids help to prevent dehydration and facilitate expectoration of mucus.
Choice D reason: This response is not correct because antitussive agents are not recommended for pneumonia. Antitussive agents suppress the cough reflex, which is a natural mechanism to clear the airways of secretions. Antitussive agents may increase the risk of respiratory infection and atelectasis.
Correct Answer is D
Explanation
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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