A nurse is providing care for a 6-year-old patient who was admitted due to dehydration following a tonsillectomy 26 hours ago.
The patient's vital signs are as follows: Temperature: 100.9°F, Pulse: 150 bpm (apically), Respiration: 28, Blood Pressure: 88/50, Pain: Ears 0, Throat 10 using FACES pain scale, Weight: 40 lbs.
Complete the following sentence by using the list of options as evidenced by: The patient is most at risk for:

Dehydration

Infection

Hemorrhage

Aspiration

Answer and Explanation

The Correct Answer is A

Choice A rationale

Given the patient’s history of tonsillectomy, elevated temperature, high pulse rate, and the fact that they were admitted due to dehydration, the patient is most at risk for dehydration.

Choice B rationale

While infection is a possible risk due to the recent surgery and elevated temperature, the provided information about the patient’s vital signs and history points more towards dehydration.

Choice C rationale

Hemorrhage could be a concern post-tonsillectomy, but the patient’s symptoms and history of dehydration make dehydration a more immediate risk.

Choice D rationale

Aspiration could be a risk in patients post-surgery, but given the patient’s vital signs and history, dehydration is the most immediate risk.

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Correct Answer is A

Explanation

Choice A rationale

Supervising the child in outdoor, fenced play areas is a key safety measure for toddlers. At this age, children are exploring their environment and may not be aware of potential dangers.

Fenced play areas provide a safe space for the child to play while still being under the watchful eye of the parents. This demonstrates an understanding of the child’s safety needs.

Choice B rationale

Allowing a toddler to cross the street with a 6-year-old sibling is not a safe practice. Children at this age do not have the cognitive ability to understand the dangers of traffic and cannot make safe decisions about when to cross the street. Therefore, this action does not demonstrate an understanding of the child’s safety needs.

Choice C rationale

Using an automobile booster seat with a lap belt is not appropriate for an 18-month-old toddler. According to safety guidelines, children under the age of 2 should be in a rear-facing car seat, and children between the ages of 2 and 4 should be in a forward-facing car seat with a harness. Booster seats are typically used for older children who have outgrown their forward- facing car seats. Therefore, this action does not demonstrate an understanding of the child’s safety needs.

Choice D rationale

Teaching a toddler about swimming and water safety is important, but it is not enough to ensure the child’s safety. Toddlers should always be supervised around water, even if they have had swimming lessons. Drowning is a leading cause of death in toddlers, and it can happen quickly and silently. Therefore, while teaching water safety is a good step, it needs to be combined with other safety measures.

A. Pain needs to be controlled, children will not eat or drink when in pain and can quickly become dehydrated. B. Report mild ear pain or foul breath after surgery. C. Your child may eat soft foods, no crunchy foods for the first few days. D. Your child will form scabs on their tonsils as they heal, there is no need to worry during this healing period.

Correct Answer is ["A","B","C","D"]

Explanation

Choice A rationale

After a tonsillectomy, it’s crucial to manage the child’s pain effectively. Pain can deter children from eating or drinking, which can lead to dehydration. Therefore, ensuring that the child’s pain is well managed is an essential part of post-operative care.

Choice B rationale

Mild ear pain or foul breath after surgery are common symptoms following a tonsillectomy. These symptoms do not necessarily indicate a problem, but they should be monitored. If these symptoms persist or worsen, it may be necessary to seek medical attention.

Choice C rationale

After a tonsillectomy, it’s recommended that the child eat soft foods for the first few days. Crunchy foods can irritate the throat and delay healing. Therefore, avoiding crunchy foods initially is an important part of post-operative care.

Choice D rationale

Following a tonsillectomy, it’s normal for the child to form scabs on their tonsils as they heal. This is a normal part of the healing process and is not a cause for concern.

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Naxlex Comprehensive Predictor Exams

The nurse is educating the parents of an 18-month-old toddler about safety and injury prevention. Which action by the parents best demonstrates their understanding of the child’s safety needs?

Correct Answer is A

Explanation

What instructions must the nurse include in the post-operative discharge instruction for a 6-year-old who just had a tonsillectomy? (Select All That Apply).

Correct Answer is ["A","B","C","D"]

Explanation

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