RN HESI Paediatrics Exam 2
RN HESI Paediatrics Exam 2 ( 53 Questions)
While obtaining the vital signs of a 10-year-old child who had a tonsillectomy this morning, the nurse observes the child swallowing every 2 to 3 minutes. Which assessment should the nurse implement?
Assessing for teeth clenching or grinding is not the most appropriate assessment in this situation. While teeth clenching or grinding may indicate discomfort or anxiety, it may not directly address the specific concern of post-operative bleeding after a tonsillectomy.
Observing a child who has had a tonsillectomy frequently swallowing may raise concerns about post-operative bleeding. Inspecting the posterior oropharynx is essential to assess for any signs of bleeding, such as fresh blood or bleeding sites.
Asking the child to speak to evaluate a change in voice tone is not the primary assessment needed in this scenario. The primary concern is to assess for any signs of bleeding, and this can be done by inspecting the posterior oropharynx.
Touching the tonsillar pillars to stimulate the gag reflex is not necessary and may not be well-tolerated by the child who has had a tonsillectomy. It's also not the primary assessment to address the concern of post-operative bleeding.
A. Assessing for teeth clenching or grinding is not the most appropriate assessment in this situation. While teeth clenching or grinding may indicate discomfort or anxiety, it may not directly address the specific concern of post-operative bleeding after a tonsillectomy.
B Inspect the posterior oropharynx.
Observing a child who has had a tonsillectomy frequently swallowing may raise concerns about post-operative bleeding. Inspecting the posterior oropharynx is essential to assess for any signs of bleeding, such as fresh blood or bleeding sites.
C. Asking the child to speak to evaluate a change in voice tone is not the primary assessment needed in this scenario. The primary concern is to assess for any signs of bleeding, and this can be done by inspecting the posterior oropharynx.
D. Touching the tonsillar pillars to stimulate the gag reflex is not necessary and may not be well-tolerated by the child who has had a tonsillectomy. It's also not the primary assessment to address the concern of post-operative bleeding.