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. Mixing the medication with formula may not be appropriate as the infant has vomited, and re-administering the medication immediately may result in overdosing.
B. Giving an antiemetic is not indicated unless ordered by the healthcare provider. It is important to follow specific orders in this situation.
C. Increasing fluid intake may not be advisable immediately after vomiting, especially in the context of heart failure. The infant may require evaluation for fluid status before increasing intake.
D. Administering the next dose as prescribed is the appropriate action unless contraindicated by specific circumstances or healthcare provider orders.
Correct Answer is D
Explanation
A) Abrasions on the knees could result from normal childhood activities and may not indicate physical abuse.
B) Front deciduous teeth missing could be due to normal tooth loss.
C) Weight in the 45th percentile is within a normal range and does not necessarily indicate physical abuse.
D) Bruising around the wrists is concerning for physical abuse, especially in a pattern consistent with restraining or gripping.
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