A nurse is caring for a 5-year-old child who is 3 hours post-operative uncomplicated tonsillectomy. Which of the following actions are appropriate post op care? (SELECT ALL THAT APPLY)

Promote quiet activities and rest

Provide liquids with straws

Closely monitor ABC

Monitor and treat pain

Apply ice collar as ordered

Answer and Explanation

Correct Answer : A,C,D,E

A.   Quiet activities and rest should be promoted to ensure the child is not overstimulated and to allow for proper recovery.
B.   Liquids should be given without straws to avoid potential injury to the surgical site.
C.   Monitoring the airway, breathing, and circulation (ABC) is essential, particularly in the first few hours post-surgery.
D.   Pain management is critical to ensure the child’s comfort and to help with healing.
E.   Applying an ice collar can help reduce swelling and pain after a tonsillectomy.

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Correct Answer is ["C","D","E"]

Explanation

A. Normal feeding and swallowing would not be expected in a newborn with TEF, as they typically have difficulty feeding and may choke or cough.
B. Sunken abdomen is not a typical finding for TEF.
C. Excessive drooling is a common symptom due to the inability to swallow saliva properly.
D. Respiratory distress is a hallmark sign of TEF, as the fistula can lead to aspiration and breathing difficulties.
E. Coughing or choking during feeding is another classic sign of TEF due to the abnormal connection between the esophagus and the trachea.

A. "This is a concern, but strabismus is easily treated with patching." B. "I will take your baby to the nursery for further examination." C. "This occurs because newborns lack muscle control to regulate eye movement." D. "I will call your primary care provider to report your concerns."

Correct Answer is C

Explanation

A. While strabismus may be treated with interventions such as patching, it is not always immediately concerning in newborns. The nurse should first provide accurate information about normal development.
B. Taking the baby to the nursery may not be necessary unless the child’s condition worsens or there is a
clear concern. A thorough assessment and explanation by the nurse are more appropriate.
C. Strabismus is common in newborns due to the immaturity of eye muscle control and usually resolves as the child develops. This is the most therapeutic response as it provides reassurance based on developmental norms.
D. Calling the primary care provider might be premature unless the nurse identifies a significant concern beyond normal development.

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A nurse is caring for a 5-year-old child who is 3 hours post-operative uncomplicated tonsillectomy. Which of the following actions are appropriate post op care? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a newborn with a diagnosis of tracheoesophageal fistula (TEF). Which of the following assessment findings may be present in a newborn with TEF? (Select All that Apply.)

Correct Answer is ["C","D","E"]

Explanation

A nurse is caring for a new mother who is concerned that her newborn has strabismus. Which of the following statements is a therapeutic response by the nurse?

Correct Answer is C

Explanation

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