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 B
Explanation
Choice A reason: This is not a valid basis for the nurse's response, as it implies that the child sleeps with the parents because of a lack of attention during the day. This may not be the case, and it may also offend the parents by questioning their parenting skills.
Choice B reason: This is a valid basis for the nurse's response, as it acknowledges the diversity and variability of family practices and preferences. It also shows respect and sensitivity for the parents' and the child's needs and comfort.
Choice C reason: This is not a valid basis for the nurse's response, as it is false and exaggerated. Sleeping with one's children is not illegal or abusive, unless there is evidence of harm or neglect. It may also alarm and anger the parents by accusing them of a crime.
Choice D reason: This is not a valid basis for the nurse's response, as it is based on a rigid and arbitrary developmental milestone. There is no fixed age for separating from parents, and it may vary depending on the child's temperament, attachment, and environment. It may also pressure and guilt the parents by implying that they are delaying their child's growth.
Correct Answer is C
Explanation
Choice A reason: This is not a relevant question for the admission history, as it does not address the child's current condition or treatment plan. It may also be perceived as insensitive or judgmental by the parents.
Choice B reason: This is not a pertinent question for the admission history, as it does not relate to the child's medical history or needs. It may also be seen as intrusive or irrelevant by the parents.
Choice C reason: This is an appropriate question for the admission history, as it acknowledges the cultural beliefs and practices of the parents and the child. It also helps the nurse to identify any potential interactions or conflicts between the tribal healer's recommendations and the medical treatment.
Choice D reason: This is a valid question for the admission history, as it informs the nurse of any alternative therapies or substances that the child may have received or ingested. It also helps the nurse to assess the effectiveness and safety of the herbal remedies, and to prevent any adverse effects or interactions with the prescribed medications.
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