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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Fruit juice is high in sugar and does not provide the same hydration as water. It is important to limit juice intake to avoid overconsumption of sugars and to encourage water as the primary fluid.
B. Allowing a toddler unlimited sweets and snacks is not advisable, as it can lead to poor nutritional habits and imbalanced diet. Picky eating should be addressed with nutritious alternatives, not by offering sweets.
C. Offering a variety of foods from different food groups ensures a balanced diet that includes essential nutrients for growth and development. This is the correct approach for toddler nutrition.
D. Dairy products are an important source of calcium and vitamin D for toddlers. Avoiding them without a medical reason can result in nutritional deficiencies.
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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