Hello, i'm an LPN in school for my RN, this test question is driving me crazy......what would you answer. Your caring for a child who just had a tonsilectomy, what would be the first thing the nurse would address?
A. PT c/o pain in hes throat when he swallows.
B. Bright red blood noted in emesis.
C. Child falls asleep during your assesment.
I choose C. b/c even though child may be tired after surgery, I think it would be unusual for PT to fall asleep DURING assesment. also, how do you know they fell asleep??? ABC's of nursing right? Many other students chose B. d/t s/s of hemorage.
OK then I must be wrong. The question staes what is the FIRST thing to address. Now clearly you would address all three issues. But I thaught one can't asume one is sleeping, couldn't this be a possible Airway issue? So if PT falls asleep during your assesment, wouldn't you check to make sure it's nothing more serious and that PT actualy did fall asleep. So confused b/c I know bleeding is important to.
Here is another way to look at it , which would you address if the patient presented with all three? so obviously it would be B, because the haemorrhage would need an immediate response.
Specializes in CNA, Surgical, Pediatrics, SDS, ER.
I'm w/ everyone else the answer is B.
We care for tonsillectomies frequently and falling or staying asleep through the assessment is not uncommon until the sedation wears off a little. Pain is normal w/ swallowing for a tonsillectomy and B would warrant further monitoring esp. since it's bright red blood risk for hemorhage/airway issues.
B, hands down. Bleeding is a complication after this type of surgery. The area is vascular and little bleeds could be missed during the surgery related to the anatomical area.
Ok, I will not answer this question or any other nursing exam related question!! I have had enough of them and no matter how it turned out, I could come up with a rationale to make every answer the right one, so I WILL NOT answer this question!!
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Babs0512
846 Posts
I'm with all the others, B.
Always remember airway, airway, airway comes first.!!
:typing