A 5-year-old client is admitted for a tonsillectomy with adenoidectomy. What is the most important question for a nurse to ask while preparing the client for surgery?
"Does the child have a sore throat currently?”.
"Do the caregivers have soft foods at home for the child?”.
"When was the last time the child ate or drank anything?”.
"Does the child have any questions about the procedure?".
The Correct Answer is C
Choice A rationale:
"Does the child have a sore throat currently?”. This choice is important but not the most critical question. The surgery involves tonsillectomy and adenoidectomy, so the child's current sore throat might not be as pertinent as other factors.
Choice B rationale:
"Do the caregivers have soft foods at home for the child?”. This choice is important for post-operative care, but the most crucial consideration is the child's fasting status before surgery.
Choice C rationale:
"When was the last time the child ate or drank anything?”. This choice is correct. It is essential to determine the child's fasting status before surgery to prevent potential complications related to anesthesia and surgery.
Choice D rationale:
"Does the child have any questions about the procedure?”. While ensuring the child's understanding is important, it is not the most critical question regarding preparation for the surgery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
X-linked dominant disorders are characterized by a mutation on the X chromosome that results in the expression of the trait in both males and females. Hemophilia, however, is more commonly associated with males, which is not consistent with an X-linked dominant pattern.
Choice B rationale:
Autosomal recessive disorders require the inheritance of two mutated alleles, one from each parent, to express the trait. Hemophilia does not follow this pattern, as the patient's sisters do not have the condition despite having affected parents.
Choice C rationale:
Autosomal dominant disorders only require the inheritance of one mutated allele from an affected parent to express the trait. Hemophilia does not align with an autosomal dominant pattern, as the patient's sisters would likely be affected if it were.
Choice D rationale:
Hemophilia is a classic example of an X-linked recessive disorder. The gene responsible for producing clotting factor is located on the X chromosome, and males have only one X chromosome, making them more susceptible to the disorder. Females, with two X chromosomes, usually act as carriers unless both X chromosomes carry the mutation.
Correct Answer is B
Explanation
Choice A rationale:
Planning for nurses to provide feedings is not necessary since this is not related to the nursing care plan and doesn't address the mother's concern.
Choice B rationale:
Reporting the finding to the health care provider is appropriate because vomiting after surgical repair of hypertrophic pyloric stenosis could indicate a potential complication or issue.
Choice C rationale:
Assuring the mother that vomiting after surgical repair is normal might not be accurate and could dismiss a potentially significant concern.
Choice D rationale:
Telling the mother it is all right to feel anxious doesn't address the vomiting concern directly and might not be the most pertinent response at this time.
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