A nurse is caring for a child post-operative tonsillectomy, what is the nursing priority when providing post-operative care?

Administer codeine postoperatively for pain management.

Offer the child a straw to drink fluids more easily.

Encourage the child to blow their nose gently to clear any mucus or secretions.

Monitor for evidence of bleeding, such as frequent swallowing or bright red emesis.

Answer and Explanation

The Correct Answer is D

A.   Although pain management is an important aspect of post-operative care, opioid use such as codeine is generally avoided in children due to the risk of respiratory depression and other side effects. Non- opioid pain relievers are preferred for post-tonsillectomy care.
B.   While it is important for the child to stay hydrated after a tonsillectomy, using a straw can increase the risk of trauma to the surgical site, leading to bleeding. The nurse should encourage sipping liquids carefully without using a straw.
C.   Blowing the nose after a tonsillectomy can cause pressure that may disrupt the healing tissue, increasing the risk of bleeding. This action should be avoided in the post-operative period.
D.   Bleeding is a significant concern after a tonsillectomy, especially in the first 24 hours. Frequent swallowing may indicate that the child is swallowing blood, and bright red emesis (vomiting) may also signal active bleeding. Monitoring for signs of bleeding is the nursing priority, as it can be life- threatening if not addressed promptly.

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

Explanation

A. Although facial pain could be concerning, it is not the immediate priority when the child has a history of atlantoaxial instability and is presenting with signs that could indicate spinal cord compression. Facial pain does not suggest a direct threat to the spinal cord, which is a more critical concern in this case.
B. Continuous neck pain in a child with atlantoaxial instability is a significant priority and requires immediate intervention. This could be a sign of spinal cord compression or injury to the cervical spine, which can occur after trauma such as a fall. Since this child has a predisposition for atlantoaxial instability, there is a high risk for neck instability and spinal cord injury, making this a top priority.
C. While lower extremity pain may be concerning, it is not as high a priority as neck pain in this context. The primary concern here is potential spinal cord compression or neurological injury. If the child is able to move their extremities or does not have severe pain or weakness, this may not require as urgent intervention. However, it should still be monitored closely.
D. Loss of bladder control is a red flag in children with suspected spinal cord injury. It can indicate nerve involvement in the spinal cord or cauda equina, which can be caused by injury or compression, particularly in a child with atlantoaxial instability. This requires priority intervention to prevent further damage and to initiate appropriate care (e.g., neurological assessment, imaging, and potentially surgical intervention).
E. The loss of established motor skills is another concerning sign. In this child, it may indicate neurological impairment or spinal cord injury. Since the child has atlantoaxial instability, this is a critical symptom that suggests the possibility of spinal cord compression or injury, requiring immediate evaluation and intervention to prevent permanent neurological damage.

A. Rotavirus B. Influenza C. Diptheria, Tetanus, and Pertussis (DTaP) D. Measles, Mumps, and Rubella (MMR)

Correct Answer is C

Explanation

A. Rotavirus is given earlier in infancy, typically before 8 months of age, and is not a priority at 18 months.
B. Influenza is important but is given seasonally, and the child is not necessarily due for this vaccine at 18 months unless indicated.
C. DTaP is a routine vaccine administered at 18 months as part of the series of childhood immunizations.
D. MMR is given at 12-15 months and again at 4-6 years, so it is not typically prioritized at 18 months if the child has already received it.

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A nurse is caring for a child post-operative tonsillectomy, what is the nursing priority when providing post-operative care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

A nurse at the well-baby clinic is preparing to give an immunization vaccine to an 18-month-old child. Which vaccine should the nurse prioritize for administration?

Correct Answer is C

Explanation

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