Exhibits

A nurse is caring for a child who is 2 hr postoperative. Which of the following actions should the nurse take first? (Click the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

Assess the child's pain level.

Recheck the child's temperature.

Determine the child's sedation level.

Compare the child's pedal pulses.

Answer and Explanation

The Correct Answer is D

A. Assessing the child's pain level is important but may not be the first priority postoperatively, especially if there are signs of compromised circulation.

B. Rechecking the child's temperature is important but may not be the first priority postoperatively unless there are specific concerns related to temperature regulation.

C. Determining the child's sedation level is important for monitoring but may not be the first priority unless there are signs of respiratory compromise or other urgent concerns.

D. Comparing the child's pedal pulses is crucial in this situation as the child has undergone surgical procedures on the lower extremity, and changes in pedal pulses could indicate compromised circulation, which requires immediate attention to prevent complications such as compartment syndrome.

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Correct Answer is C

Explanation

A. Refusing clear liquids is common after surgery, but it is not the most concerning finding.

B. Crying is a normal response for a child in the immediate postoperative period and is not as urgent as frequent swallowing.

C. Frequent swallowing after a tonsillectomy can indicate bleeding, which is a serious complication that needs immediate attention.

D. Increased throat pain can be expected after surgery and is typically managed with analgesics, so it is not a priority.

A. Request assistance from the anesthesiologist to clarify the misunderstanding. B. Notify the provider who is scheduled to perform the procedure. C. Explain the procedure to the adolescent and their guardian. D. Witness the adolescent's signature on the informed consent form.

Correct Answer is B

Explanation

A. The anesthesiologist would typically explain their role, but the primary responsibility for explaining the procedure lies with the provider performing it.

B. If a guardian does not understand the procedure, the nurse should notify the provider to ensure that the guardian receives a full explanation. The provider is responsible for clarifying any misunderstandings regarding the procedure.

C. While the nurse can provide general information, the provider must explain the details of the procedure to ensure informed consent is obtained.

D. The nurse should not witness the consent unless the guardian fully understands and consents to the procedure.

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Exhibits A nurse is caring for a child who is 2 hr postoperative. Which of the following actions should the nurse take first? (Click the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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Exhibits

A nurse is caring for a child who is 2 hr postoperative. Which of the following actions should the nurse take first? (Click the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)