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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. Examining the child for skin irritation at the cast edges is important to prevent complications, but it is not the priority over monitoring for circulation and potential complications.
B. Restricting strenuous activities is important for preventing damage to the cast, but it is not the priority over monitoring for circulatory compromise.
C. Monitoring for pallor or swelling in the child's affected hand is the priority because it indicates potential circulatory compromise, which is a critical concern following cast application.
D. Using a hair dryer on a cool setting to relieve itching is a helpful suggestion, but it is not the priority over monitoring for potential complications.

A. Place the child in a prone position. B. Clear the area of hard objects. C. Insert a tongue blade between the teeth. D. Minimize movement of the limbs.

Correct Answer is B

Explanation

Rationale:
A) Placing the child in a prone position can obstruct the airway and increase the risk of aspiration.
B) Clearing the area of hard objects helps prevent injury during a seizure.
C) Inserting a tongue blade between the teeth can cause oral trauma and should be avoided.
D) Minimizing movement of the limbs is not necessary during a seizure; the focus should be on ensuring safety and preventing injury.

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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?

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