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.

Answer and Explanation

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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Correct Answer is D

Explanation

A. "Chill the medication prior to administration." The medication should be warmed to room temperature to prevent discomfort or dizziness during administration.
B. "Pull the pinna up and back during medication administration." For infants, the pinna should be pulled down and back to straighten the ear canal.
C. "Hyperextend the infant's neck during medication administration." Hyperextending the neck is unnecessary and may cause discomfort; a neutral position is sufficient.
D. "Massage the anterior area of the ear following administration." Massaging the tragus helps ensure the medication is evenly distributed into the ear canal.

A. A 15-year-old client who requires an open reduction of a fracture. B. A 6-month-old infant requiring IV antibiotics. C. 14-year-old client seeking prenatal care. D. A 5-year-old child requiring a chest x-ray.

Correct Answer is A

Explanation

A. A 15-year-old client who requires an open reduction of a fracture. Minors generally require parental or guardian consent for surgical procedures unless emancipated.
B. A 6-month-old infant requiring IV antibiotics. Informed consent from the guardian is required for medical interventions like IV antibiotics in infants.
C. A 14-year-old client seeking prenatal care. Pregnant minors in many jurisdictions are allowed to consent for their own prenatal care without a guardian's approval.
D. A 5-year-old child requiring a chest x-ray. While routine x-rays require parental consent, in an emergency, consent may not be necessary if immediate care is required to stabilize the child.

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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?

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