A nurse is assessing a preschool-age child who is in the immediate postoperative period following a tonsillectomy. Which of the following assessment findings is the priority?
The child's throat pain increases.
The child refuses clear liquids.
The child cries often.
The child swallows frequently.
The Correct Answer is D
Rationale:
A. The child's throat pain is expected post-tonsillectomy and can be managed using analgesics or an ice collar. However, this is not a priority finding compared to frequent swallowing which may indicate bleeding which is a life-threatening complication of tonsillectomy.
B. Refusing clear liquids may indicate discomfort but is not as urgent as a potential increase in throat pain.
C. Crying often may be a response to discomfort but does not necessarily indicate a complication requiring immediate intervention.
D. This assessment finding indicates that the child might have bleeding in the throat, which is a life-threatening complication of tonsillectomy. The nurse should
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Related Questions
Correct Answer is D
Explanation
A. A heart rate of 54/min is within the normal range for a 5-year-old child and does not specifically indicate hemorrhage.
B. Flushing of the face is not a direct indicator of hemorrhage.
C. A blood pressure of 95/56 mm Hg may be within the normal range for a 5-year-old child and does not specifically indicate hemorrhage.
D. Continuous swallowing can indicate bleeding in the postoperative period following a tonsillectomy and adenoidectomy, as blood may be pooling in the throat and swallowed rather than expectorated.
Correct Answer is D
Explanation
Rationale:
A. The child's throat pain is expected post-tonsillectomy and can be managed using analgesics or an ice collar. However, this is not a priority finding compared to frequent swallowing which may indicate bleeding which is a life-threatening complication of tonsillectomy.
B. Refusing clear liquids may indicate discomfort but is not as urgent as a potential increase in throat pain.
C. Crying often may be a response to discomfort but does not necessarily indicate a complication requiring immediate intervention.
D. This assessment finding indicates that the child might have bleeding in the throat, which is a life-threatening complication of tonsillectomy. The nurse should
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