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 reason: Respiratory tract infection is not a correct answer because it is not a complication of examining the child's throat. It is a possible cause of epiglottitis, which is an inflammation of the epiglottis, the flap that covers the entrance to the trachea.
Choice B reason: Sore throat is not a correct answer because it is not a complication of examining the child's throat. It is a symptom of epiglottitis, along with fever, difficulty swallowing, and drooling.
Choice C reason: Complete airway obstruction is the correct answer because it is a life-threatening complication of examining the child's throat. The tongue depressor can trigger a spasm of the epiglottis, which can block the airway and cause respiratory distress or arrest.
Choice D reason: Inspiratory stridor is not a correct answer because it is not a complication of examining the child's throat. It is a sign of upper airway obstruction, which can occur in epiglottitis, but it is not caused by the tongue depressor.
Correct Answer is C
Explanation
Choice A reason: This response is not correct because a faster heart rate does not necessarily imply respiratory compromise. A child's heart rate is normally faster than an adult's due to the smaller size and higher metabolic rate of the child.
Choice B reason: This response is not correct because a greater body surface area does not directly affect the respiratory system. A child's body surface area is larger than an adult's in proportion to their body weight, which means they lose heat more easily and are more prone to hypothermia.
Choice C reason: This response is correct because a narrower airway diameter makes the child more susceptible to airway obstruction, inflammation, and edema. A child's airway is about one-third the size of an adult's, which means that even a small amount of swelling or secretions can significantly reduce the airway caliber and cause respiratory distress.
Choice D reason: This response is not correct because the ability to verbalize is not a factor that contributes to respiratory compromise. However, the inability to verbalize may make it harder for the child to communicate their symptoms and needs, which may delay the recognition and treatment of respiratory problems.
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