A nurse is caring for a school-age child who is 1 hr postoperative following a tonsillectomy.
Which of the following actions should the nurse take? (Select all that apply.)
Maintain the child in a supine position.
Provide cranberry juice to the child.
Discourage the child from coughing.
Administer an analgesic to the child on a scheduled basis.
Observe the child for frequent swallowing.
Correct Answer : D,E
A. Maintaining the child in a supine position is not recommended after a tonsillectomy.
The child should be positioned on their side to prevent aspiration.
B. Cranberry juice is acidic and may be irritating to the surgical site. Clear, non-acidic fluids are usually recommended after a tonsillectomy.
C. While coughing should be minimized to prevent irritation to the surgical site, the child should not be discouraged from coughing if needed to clear secretions.
D. Administering an analgesic on a scheduled basis is important for managing pain after a tonsillectomy. This helps to maintain a consistent level of pain control.
E. Observing the child for frequent swallowing is important, as it may indicate bleeding or discomfort. This is a key assessment after a tonsillectomy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Increased restlessness can indicate hypoxia, pain, or worsening shock, which are critical concerns in a toddler with significant burns. This finding should be reported immediately.
B. Respiratory rate of 25/min is within the normal range for a toddler (22-37 breaths per minute) and does not require immediate intervention.
C. Bowel sounds of 20/min are normal and do not indicate a complication.
D. Urinary output of 35 mL/hr is adequate for a toddler (goal: ≥1-2 mL/kg/hr, which would be ≥20-40 mL/hr for a 20 kg child) and does not require reporting.
Correct Answer is ["A","B","C"]
Explanation
A. Providing a high-calorie diet is important for a child with extensive burns to support wound healing and recovery.
B. Monitoring intake and output is crucial to assess fluid balance and ensure that the child is receiving enough fluids and nutrients for healing.
C. Changing dressings using an aseptic technique helps prevent infection, which is a significant risk in burn wounds.
D. Removing splints during sleep is not recommended, as they are in place to prevent contractures. They should be worn consistently, including during sleep.
E. Administering analgesics IM (intramuscularly) is not typically indicated. Pain
management can be achieved through various routes, and IM administration may not be necessary. Additionally, it's important to consider the child's pain level and choose the most appropriate and effective route for analgesia.
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