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: The child's current vital signs are not a reliable indicator of pain, as they may vary depending on the child's condition, medication, and stress level. Vital signs alone are not sufficient to assess pain in children.

Choice B reason: The child becoming quiet when held and cuddled may indicate that the child is comforted by the nurse's presence and touch, not that the child is in pain. In fact, some children may become more vocal and restless when they are in pain.

Choice C reason: The child having just returned from the recovery room does not necessarily mean that the child is in pain. The child may have received pain medication during or after the surgery, or the child may have a different pain threshold. The nurse should not assume that the child is in pain based on the procedure alone.

Choice D reason: The child lying rigidly in bed and not moving is a sign of pain in children, as they may try to avoid movement that could aggravate their pain. The child may also exhibit facial expressions, such as grimacing, frowning, or clenching their teeth, that indicate pain. The nurse should assess the child's pain level and administer pain medication as ordered.

A. Of course you have a mommy. You just don't live with your mommy. B. It must be interesting to live with two men and no women in the household. C. I'll call one of your daddies to come pick you up. D. That's right. I forgot your parents are gay.

Correct Answer is C

Explanation

Choice A reason: This is not appropriate because it denies the child's reality and implies that having two daddies is not normal. It may also hurt the child's feelings and make them feel ashamed of their family.

Choice B reason: This is not appropriate because it sounds judgmental and curious about the child's family structure. It may also make the child feel uncomfortable and different from other children.

Choice C reason: This is appropriate because it accepts the child's statement and shows respect for their family. It also focuses on the child's immediate need and comfort.

Choice D reason: This is not appropriate because it sounds sarcastic and dismissive of the child's family. It may also make the child feel angry and defensive.

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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?

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Naxlex Comprehensive Predictor Exams

Which assessment indicates to a nurse that a school-age child is in need of pain medication?

Correct Answer is D

Explanation

A second grader enters the school nurse's office crying and states, "I feel sick. My tummy hurts." The nurse replies, "I'll call your mommy or daddy to come pick you up." The child replies, "I don't have a mommy. I have two daddies." Which of the following comments by the nurse is appropriate?

Correct Answer is C

Explanation

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