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
Explanation
Choice A reason: Stridor is a high-pitched, harsh sound that occurs during inspiration. It is caused by the narrowing of the upper airway due to inflammation and edema. Stridor is a characteristic sign of croup, also known as laryngotracheobronchitis.
Choice B reason: Wheezes are high-pitched, musical sounds that occur during expiration. They are caused by the narrowing of the lower airway due to bronchoconstriction or mucus. Wheezes are more common in asthma than in croup.
Choice C reason: Crackles are fine, crackling sounds that occur during inspiration. They are caused by the opening of collapsed or fluid-filled alveoli. Crackles are more common in pneumonia or heart failure than in croup.
Choice D reason: Rhonchi are low-pitched, snoring sounds that occur during expiration. They are caused by the vibration of mucus in the large airways. Rhonchi are more common in bronchitis or cystic fibrosis than in croup.
Correct Answer is A
Explanation
Choice A reason: This is the most appropriate action because it respects the youth's autonomy and maturity, and allows for timely and necessary intervention. Assent is the agreement of a minor to participate in a medical decision, and it is usually sufficient in emergency situations when parental consent is not available.
Choice B reason: This is not the most appropriate action because it may delay the surgery and put the youth at risk of further complications. Another relative may not have the legal authority to consent for the youth, and may not be reachable in time.
Choice C reason: This is not the most appropriate action because it does not address the underlying problem of the injury. Pain medications may provide temporary relief, but they may also mask the symptoms and interfere with the surgery.
Choice D reason: This is not the most appropriate action because it may jeopardize the youth's health and safety. Waiting for parents to obtain consent may result in irreversible damage or even death. The youth's best interest should be the priority in this case.
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