A nurse is caring for a school age child who is 1 hour postoperative following a tonsillectomy.
Which of the following actions should the nurse take?
. Discourage the child from coughing
Provide cranberry juice to the child
Maintain the child in a supine position
Administer an analgesic to the child on a schedule basis
Correct Answer : A
The correct answer is choice a. Discourage the child from coughing.
Choice A rationale:
Discouraging the child from coughing is important because coughing can dislodge clots and cause bleeding at the surgical site, which is a common complication after a tonsillectomy.
Choice B rationale:
Providing cranberry juice to the child is not recommended because acidic juices can irritate the throat and cause discomfort or pain.
Choice C rationale:
Maintaining the child in a supine position is not ideal as it can increase the risk of aspiration. Instead, the child should be positioned on their side or with the head elevated to facilitate drainage and reduce the risk of aspiration.
Choice D rationale:
Administering an analgesic to the child on a scheduled basis is important for pain management, but it is not the most immediate action to take one hour postoperatively. Pain management should be part of the overall care plan.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Giving water after administering digoxin helps ensure that the medication is swallowed and reaches the stomach, which is important for proper absorption.
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale: Assisting with intubation is the priority action. A submersion injury can cause respiratory distress or failure, and ensuring a clear airway is critical. Intubation is often necessary to maintain oxygenation and prevent complications like hypoxia or aspiration.
Choice B rationale: Obtaining an ABG sample is important to assess the child’s oxygenation and acid-base balance, but it is not the priority action. Ensuring the airway is clear and secured takes precedence over diagnostic tests.
Choice C rationale: Administering an IV bolus might be necessary for fluid resuscitation if the child is experiencing shock, but establishing and maintaining the airway is the first critical step in managing submersion injuries.
Choice D rationale: Applying warming blankets can be important to prevent hypothermia, especially if the child has been in cold water. However, addressing airway and breathing issues is the top priority before initiating warming measures.
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