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 B
Explanation
A. Injecting the immunizations into the deltoid muscle may be appropriate for older children or adults but not for infants.
B. Providing a pacifier coated with an oral sucrose solution has been shown to reduce pain and distress during injections in infants, promoting atraumatic care.
C. A 20-gauge needle may cause more pain and tissue trauma in infants compared to a smaller gauge needle.
D. EMLA cream is not typically recommended for immunizations in infants as it requires time to take effect and may not provide adequate pain relief during the procedure.
Correct Answer is A
Explanation
A. Packed red blood cells should typically be infused within 4 hours to reduce the risk of bacterial contamination and ensure potency.
B. Dextrose 5% in water is not typically infused with packed RBCs; the focus is on administering blood products as prescribed.
C. Blood products are typically stored under controlled conditions and transfused promptly after verification and compatibility checks.
D. Filtered IV tubing is often used for blood transfusions to minimize the risk of air embolism and particle infusion, but it's not the primary intervention listed for the scenario.
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