A nurse is caring for a toddler who is 24 hours postoperative following a cleft palate repair. Which of the following actions should the nurse take?
Apply bilateral wrist restraints.
Administer opioids for pain.
Implement a soft diet.
Offer fluids through a straw.
The Correct Answer is C
Choice A reason: Apply Bilateral Wrist Restraints
Applying bilateral wrist restraints can be necessary in some cases to prevent the child from touching or interfering with the surgical site. However, restraints should be used as a last resort and only when absolutely necessary. They can cause distress and discomfort to the child and should be monitored closely to prevent any complications.
Choice B reason: Administer Opioids for Pain
Administering opioids for pain management is a common practice post-surgery to ensure the child is comfortable. However, opioids should be used cautiously due to the risk of side effects and potential for dependency. Non-opioid pain management strategies, such as acetaminophen or ibuprofen, are often preferred unless the pain is severe.
Choice C reason: Implement a Soft Diet
Implementing a soft diet is crucial for a child who is 24 hours postoperative following a cleft palate repair. The surgical site in the mouth is still healing, and a soft diet helps prevent any damage or irritation to the area. Soft foods are easier to swallow and less likely to cause pain or disrupt the healing process. Examples of soft foods include mashed potatoes, yogurt, and pureed fruits.
Choice D reason: Offer Fluids Through a Straw
Offering fluids through a straw is not recommended for a child who has undergone cleft palate repair. The suction created by using a straw can put pressure on the surgical site and potentially cause complications. Instead, fluids should be offered using a cup or a spoon to minimize any risk to the healing palate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
In this scenario, the client is most likely experiencing iron deficiency anemia, based on the diagnostic results that show low hemoglobin (10 mg/dL), low hematocrit (31%), and low serum ferritin (9 mcg/L), which are below the normal ranges for a pregnant individual.
The correct answers are:
Potential Condition:
- a. Iron deficiency anemia
Actions to Take:
- a. Administer iron supplements (to address the anemia and increase iron levels)
- b. Teach the client about a diet rich in iron (to support iron supplementation and improve dietary intake of iron)
Parameters to Monitor:
- a. Hemoglobin levels (to assess improvements in oxygen-carrying capacity and monitor for anemia)
- b. Hematocrit levels (to monitor the volume of red blood cells and further assess anemia)
By addressing the low iron levels, administering supplements, and providing dietary guidance, the nurse can help correct the anemia. Monitoring hemoglobin and hematocrit will help track the client’s progress in overcoming the condition.
Correct Answer is ["4"]
Explanation
Step 1: Determine the dosage required. Required dosage = 40 mg
Step 2: Determine the concentration of the available solution. Available concentration = 10 mg/mL
Step 3: Calculate the volume to be administered. Volume to be administered = Required dosage ÷ Available concentration Volume to be administered = 40 mg ÷ 10 mg/mL
Step 4: Perform the division. 40 ÷ 10 = 4
= The nurse should administer 4 mL.
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