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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Related Questions
Correct Answer is C
Explanation
A. Educate the infant's caregiver about the feeding: While important, education should occur after ensuring the prescription is correct.
B. Flush the feeding tube before the feeding: This ensures patency but should only be done after verifying the prescription.
C. Clarify the feeding prescription with the provider. Bolus feedings are typically contraindicated with nasojejunal tubes because the jejunum cannot handle large volumes at once. Continuous feedings are usually prescribed. The prescription should be clarified before proceeding.
D. Place a label on the feeding bag and tubing: Labeling is necessary for safety but is not the priority when the prescription may be inappropriate.
Correct Answer is B
Explanation
A. "Administer the medication on an empty stomach." Phenytoin can be taken with or without food. Administering with food can reduce stomach upset.
B. "Encourage the child to brush their teeth after each meal." Phenytoin increases the risk of gingival hyperplasia, so regular brushing helps maintain oral hygiene and prevents complications.
C. "Crush the child's medication to mix with applesauce." Extended-release capsules should not be crushed as this alters their intended release mechanism.
D. "Observe the child for diarrhea." Diarrhea is not a common side effect of phenytoin. Monitoring should focus on side effects like gingival overgrowth, nystagmus, or skin rashes.
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