Assigned to a 9-year-old pediatric client who is 8 hours post-tonsillectomy, a practical n… — NCLEX-PN

Assigned to a 9-year-old pediatric client who is 8 hours post-tonsillectomy, a practical nurse (PN) reviews the medication administration record. The child weighs $66\text{ lbs}$ ( $30\text{ kg}$ ) and has a prescription for oral acetaminophen $15\text{ mg/kg/dose}$ every 4 hours PRN for moderate pain. The unit's automated dispensing cabinet supplies an acetaminophen oral suspension of $160\text{ mg}/5\text{ mL}$ .

While obtaining the client's vital signs, the PN documents the following data:

Assessment	Finding
Heart Rate	$128\text{ bpm}$
Blood Pressure	$92/58\text{ mmHg}$
Respiratory Rate	$22\text{ breaths/min}$
Behavior	Restless, frequent swallowing

The charge registered nurse (RN) is currently stabilizing another patient and verbally instructs the PN to "go ahead and give the child $14\text{ mL}$ of the PRN acetaminophen to manage their throat pain."

Which action demonstrates the most appropriate clinical judgment by the PN?

Withhold the oral medication, maintain the client on nothing by mouth (NPO) status, and immediately alert the RN to assess for possible hemorrhage.Cevap
B
Calculate the dosage as $31\text{ mL}$ based on the client's weight in pounds, verify the medication rights, and administer the suspension.
C
Administer the $14\text{ mL}$ of medication as delegated, because frequent swallowing and tachycardia are expected physiological manifestations of acute throat pain.
D
Accept the delegated task, but first use a tongue depressor and penlight to independently perform a comprehensive assessment of the tonsillar beds for active bleeding.

Cevap

The most appropriate action is to withhold the oral medication, maintain the client on NPO status, and immediately alert the RN to assess for possible hemorrhage.

The correct action prioritizes client safety by recognizing the classic signs of postoperative tonsillar hemorrhage (frequent swallowing, restlessness, tachycardia). Despite the RN's verbal instruction and the mathematical accuracy of the

14\text{ mL}

dose, the PN must utilize clinical judgment to withhold oral intake (preventing aspiration and maintaining NPO status for possible emergency surgery) and immediately escalate the critical findings.

Adım Adım Çözüm

Analyze the client's clinical presentation.

The client exhibits frequent swallowing, restlessness, a heart rate of

128\text{ bpm}

, and a blood pressure of

92/58\text{ mmHg}

Recognizing patterns in vital signs and behavior is essential for identifying postoperative complications like hemorrhage.

Evaluate the requested pharmacological intervention against the clinical data.

Although the RN's calculated dose of

14\text{ mL}

is mathematically correct (

30\text{ kg} \times 15\text{ mg/kg} = 450\text{ mg}

;

450 \div 160 \times 5 = 14\text{ mL}

), administering an oral medication is unsafe.

Giving oral fluids or medications to a actively bleeding post-tonsillectomy client increases aspiration risk and violates NPO status needed for potential surgical re-intervention.

Determine the appropriate action within the PN scope of practice.

The PN must refuse the unsafe delegation, withhold the medication, and escalate the critical findings to the RN.

The PN is responsible for recognizing life-threatening changes in a client's condition, withholding contraindicated medications, and communicating immediately with the RN or provider.

Anahtar Kavram

Pre-administration withholding criteria and recognizing subtle signs of postoperative hemorrhage.

Soru

Cevap

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