Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
66. A child is being prepared for a tonsillectomy. The laboratory telephones the pediatric unit and reports that the child's prothrombin time (PT) is 14.1 seconds. The nurse's first action should be to:
. Note the laboratory result in the child's chart.
. Immediately notify the pediatric surgeon.
. Call the operating room and cancel the surgery.
. Release the child to the operating room transporter.
Test-Taking Tip
The stem asks for a priority nursing action. Eliminate the two options that imply that the laboratory result is a problem ( Answers 2 and 3 ).
Content Area: Child Health, Pediatric Surgery; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Laboratory Values
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
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Answer 1 is correct because a normal prothrombin time (PT) in a child is 11 to 15 seconds. A value of 14.1 seconds is within normal limits and the child is a safe candidate for the surgery. Because the tonsillar operative site is highly vascular, bleeding is a concern and coagulation studies are always conducted prior to the surgery. Since other health-care personnel (e.g., the pediatric surgeon, operating room surgical team, etc.) will also need this information before proceeding with the surgery, the nurse's first action should be to note the laboratory result in the child's chart. Answer 2 is incorrect because the pediatric surgeon will routinely review the child's chart prior to the surgery, and will specifically look for the results of the prothrombin time (PT) before starting the surgery. There is no need for the nurse to notify the pediatric surgeon at this time because the prothrombin time is within normal limits. Answer 3 is incorrect because the prothrombin time (PT) is within normal limits and the surgery can take place as planned. If the laboratory results were not within normal limits, the nurse would call the operating room and notify them. But, it is not the nurse's role to cancel the surgery. It is the pediatric surgeon's responsibility to cancel the surgery if needed. Answer 4 is incorrect because, while it is safe to release the child to the operating room transporter, the nurse should only do so after noting the results of the prothrombin time (PT) in the child's chart.