A nurse is caring for a toddler who is 24 hr postoperative following a cleft palate repair.
Which of the following actions should the nurse take?
Apply bilateral wrist restraints.
Implement a soft diet.
Administer opioids for pain.
Offer fluids through a straw.
The Correct Answer is C
A. Applying bilateral wrist restraints is not a standard intervention after cleft palate repair.
Restraints should be used judiciously and with clear indications to prevent injury.
B. The baby can start feeding normal diet after 24hrs
C. Administering opioids for pain is an appropriate action by the nurse. Opioids control pain in the immediate postoperative period are followed by administration of acetaminophen PRN.
D. Offering fluids through a straw is contraindicated after cleft palate repair, as it can disrupt the healing process and increase the risk of complications. Sippy cups or other appropriate utensils should be used.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Staying with the child until asleep may temporarily address the fear but may not help the child develop coping skills for the future.
B. Allowing the child to sleep in the parent's bed may provide comfort but may not address the fear of monsters in the long term.
C. Keeping a night light on in the child's room can provide a sense of security and help alleviate fear by making the environment less intimidating.
D. Telling the child that monsters are not real may not be effective at this age, as young children often have difficulty distinguishing between fantasy and reality. Offering reassurance and
practical solutions like a night light may be more helpful.
Correct Answer is C
Explanation
A. Nausea and vomiting are more commonly associated with hyperglycemia or diabetic ketoacidosis, not hypoglycemia.
B. The onset of low blood glucose usually occurs quickly, not slowly.
C. Feeling shaky is a common symptom of hypoglycemia, and the parents' recognition of this symptom is indicative of an understanding of the teaching.
D. Sweating is also a symptom of hypoglycemia, not hyperglycemia.
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