A nurse is creating a plan of care for a school-age child who is postoperative following a tonsillectomy. Which of the following interventions should the nurse include?
Instruct the child to gargle using salt water every 4 hr.
Give the child fluids using a straw.
Ask the child to take deep breaths and cough every 30 min.
Apply an ice collar to the child's neck.
The Correct Answer is D
A. Instruct the child to gargle using salt water every 4 hr: Gargling can irritate the surgical site and increase the risk of bleeding.
B. Give the child fluids using a straw: Using a straw creates suction, which can dislodge the clot and cause bleeding.
C. Ask the child to take deep breaths and cough every 30 min: Coughing can increase pressure on the surgical site and lead to bleeding.
D. Apply an ice collar to the child's neck. An ice collar reduces swelling, pain, and the risk of bleeding by promoting vasoconstriction.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "I will breathe in through the mouthpiece, hold my breath for 5 seconds, and then exhale.": Incorrect because the child should exhale forcefully and quickly into the device, not inhale or hold their breath.
B. "If I get a reading in the green zone, I will tell my parents right away so they can call the doctor.": Incorrect because a green zone reading indicates controlled asthma, and no immediate action is required.
C. "I will slowly exhale through the mouthpiece over a 10-second interval.": Incorrect because the exhalation should be rapid and forceful to measure peak flow effectively.
D. "I will record the highest reading of the three attempts." Recording the highest reading ensures accurate monitoring of airway status and helps the child track their progress over time.
Correct Answer is C
Explanation
A. "The infant exhibits a fear of strangers." Stranger anxiety typically develops around 6 to 9 months of age.
B. "The infant understands the word 'no'." Understanding simple words like "no" begins closer to 9 months to 1 year of age.
C. "The infant has an absent grasp reflex." The grasp reflex begins to disappear by 3 months of age, with voluntary grasping developing by 4 to 5 months.
D. "The infant rolls from their back to their abdomen." Rolling from back to abdomen usually occurs around 5 to 6 months.
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