Nursing Prioritization Delegation Assignment Q 63

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You have obtained the following assessment information about a 3-year old who has just returned to the pediatric unit after having a tonsillectomy. Which finding requires the most immediate follow-up?

  

     A. Frequent swallowing

     B. Hypotonic bowel sounds

     C. Complaints of a sore throat

     D. Heart rate of 112 beats/min

    

    

Correct Answer: A. Frequent swallowing

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Frequent swallowing after a tonsillectomy may indicate bleeding. You should inspect the back of the throat for evidence of bleeding. The other assessment results are not unusual in a 3-year old after surgery.

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Option B: Hypoactive bowel sounds are normal during sleep. They also occur normally for a short time after the use of certain medicines and after abdominal surgery. Decreased or absent bowel sounds often indicate constipation.

Option C: It is common for the child to have a temporary sore throat for about 2-3 weeks after getting tonsils and adenoids removed. The pain will be most severe for the first week after surgery and will usually be gone in 2-3 weeks

Option D: No strenuous exercise or activity – running, jumping, swimming or playing sports – until the child’s throat is fully healed. Anything that increases the child’s heart rate or blood pressure can increase the risk of bleeding. If this occurs, it may require another surgery to stop the bleeding.

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