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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: This response is correct because a sweat chloride test is the gold standard for diagnosing CF. CF is a genetic disorder that affects the function of the chloride channels in the cells, leading to thick and sticky mucus in various organs. A sweat chloride test measures the amount of chloride in the sweat, which is abnormally high in people with CF.

Choice B reason: This response is not correct because serum calcium is not related to CF. Serum calcium is a measure of the amount of calcium in the blood, which is influenced by factors such as diet, vitamin D, parathyroid hormone, and kidney function.

Choice C reason: This response is not correct because bronchoscopy is not a diagnostic test for CF. Bronchoscopy is a procedure that involves inserting a flexible tube with a camera into the airways to examine the lungs and collect samples. Bronchoscopy may be used to treat complications of CF, such as mucus plugs or infections, but it is not essential for establishing the diagnosis.

Choice D reason: This response is not correct because urine creatinine is not a diagnostic test for CF. Urine creatinine is a measure of the amount of creatinine, a waste product of muscle metabolism, in the urine. Urine creatinine reflects the kidney function and muscle mass, but it is not affected by CF.

A. Have the youth give assent, and proceed with surgery. B. Attempt to contact another relative. C. Give pain medications until consent can be obtained. D. Wait for parents to obtain consent.

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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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?

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Cystic fibrosis (CF) is suspected in a toddler. Which test is essential in establishing this diagnosis?

Correct Answer is A

Explanation

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Explanation

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