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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is []

Explanation

Condition:

Acute Laryngotracheobronchitis (Croup)

The harsh, bark-like cough and hoarse cry are classic symptoms of croup (acute laryngotracheobronchitis), a viral infection that typically affects young children. Mild work of breathing and stridor (a high-pitched sound during inspiration) indicate upper airway narrowing, which is characteristic of croup.

Actions to Take

Prepare to administer IV steroids:

Steroids (e.g., dexamethasone) are used to reduce airway inflammation in croup and are considered first-line treatment. They help reduce the swelling in the upper airways, making breathing easier and improving stridor and cough. IV steroids are often used in more severe cases, such as in an emergency department setting.

Administer racemic epinephrine:

Racemic epinephrine is a bronchodilator used to treat moderate to severe cases of croup. It works by reducing inflammation and relaxing the muscles of the upper airway, which helps relieve stridor and airway obstruction. This medication is typically given via nebulizer in the emergency department to provide rapid relief.

Parameters to Monitor

Oxygen saturation:

It is important to monitor oxygen saturation (SpO2) to assess if the child is getting enough oxygen. Croup can lead to hypoxia if the airway becomes severely narrowed. Monitoring oxygen levels ensures that the child is not deteriorating and allows for appropriate interventions if oxygen levels fall below normal (typically below 92% or 90%, depending on clinical guidelines).

Respiratory rate:

Monitoring the respiratory rate provides insight into how well the child is maintaining adequate ventilation. In cases of croup, increased work of breathing and distress can cause a higher respiratory rate. If the rate becomes very high or very low, it may indicate worsening distress or impending respiratory failure. Regular monitoring helps guide treatment and reassessment.

A. This is normal behavior for a two-year-old child. B. The toddler isn't effectively coping with the stress. C. This behavior suggests the need for further assessment. D. The toddler's need for affection isn't being met.

Correct Answer is A

Explanation

A. It is normal for toddlers to exhibit defiance, say "no" often, and become upset when scolded as part of the development of autonomy and independence. Seeking comfort afterward is also typical.

B. While the toddler may be struggling with emotional regulation, this behavior is typical and does not necessarily indicate ineffective coping.
C. There is no indication that further assessment is necessary unless other concerns arise. This behavior is normal for the developmental stage.
D. The toddler's behavior is not necessarily due to unmet affection; it is more likely part of the developmental process.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 []

Explanation

Actions to Take

Parameters to Monitor

A nurse is speaking to the parent of a 22-month-old child who states the child says "no" to everything. When scolded, the toddler becomes angry and starts crying loudly, then later wants to be held. How should the nurse best interpret this toddler's behavior?

Correct Answer is A

Explanation

A nurse is caring for an 8-month - old child with a known dysmorphic syndrome and congenital anomalies. The nurse recognizes that the child is at risk for which of the following?

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.)

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?

A nurse is caring for a child with an eye infection. Which of the following should be included in parent teaching for the care of a child with conjunctivitis? (Select All that Apply.)

A charge nurse on a pediatric unit is observing a newly licensed nurse provide care for a child diagnosed with acute epiglottis. Which of the following actions by the newly licensed nurse indicates that the charge nurse should intervene?

A nurse is caring for an infant who has inadequate motility of a portion of the intestine, resulting in a mechanical obstruction. The nurse should identify this finding as a manifestation of which of the following disorders?

A pediatric nurse is assessing a child with otitis media that has frequent ear problems. The nurse recognizes that which of the following risk factors are associated with otitis media?