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. Protective environment: This is for immunocompromised clients, not infectious diseases like pertussis.
B. Airborne: Airborne precautions are used for diseases like tuberculosis, measles, or varicella, which spread through smaller airborne particles.
C. Contact: Contact precautions are for diseases transmitted via direct contact, such as MRSA or C. difficile, and are not appropriate for pertussis.
D. Droplet. Pertussis is transmitted through respiratory droplets, so droplet precautions (e.g., wearing a surgical mask and maintaining distance) are essential to prevent the spread.
Correct Answer is D
Explanation
A. "I will ensure that my child takes a 1-hour nap each day." Prolonged inactivity, like frequent naps, may increase joint stiffness. Physical activity should be encouraged to maintain joint mobility.
B. "I will give my child prednisone as needed for pain." Prednisone is not typically used as needed for pain. NSAIDs are the first-line treatment for inflammation and pain in JIA.
C. "I will apply cool compresses to my child's painful joints during exacerbations." Warm compresses, not cool, are typically more effective in relieving joint stiffness in JIA.
D. "I will have my child wear splints during the night." Wearing splints at night helps maintain joint position and prevent contractures.
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