The nurse is discussing discharge instructions with the parents of a 6-year-old who had a tonsillectomy. What is the most important thing to stress?
Administer analgesics.
Encourage the child to drink liquids.
Inspect the throat for bleeding.
Apply an ice collar.
The Correct Answer is C
A. Administer analgesics: Pain control is essential after a tonsillectomy to promote oral intake and comfort. Analgesics reduce throat discomfort and help the child maintain hydration and nutrition, but they do not directly prevent life-threatening complications such as postoperative hemorrhage.
B. Encourage the child to drink liquids: Hydration supports mucosal healing and prevents dehydration, which is a common postoperative concern. However, while encouraging fluid intake is important, it does not directly address the risk of sudden, severe bleeding that can occur after tonsillectomy.
C. Inspect the throat for bleeding: Post-tonsillectomy hemorrhage is the most serious complication, especially within the first 24 hours and around 5–10 days post-surgery when the scabs begin to slough. Careful observation for signs of active bleeding, such as frequent swallowing, vomiting blood, or fresh blood in the mouth, is critical to detect hemorrhage early.
D. Apply an ice collar: Ice collars can reduce local swelling and provide comfort by constricting blood vessels, helping with pain control. Although beneficial, this intervention does not address the immediate danger posed by postoperative bleeding and is secondary to monitoring for hemorrhage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["17"]
Explanation
Ordered Dose: 17 units
Available Concentration: 100 units/mL
Since insulin is dosed in units, the prescribed dose directly equals the number of units to administer
Units to administer = 17 units
Correct Answer is A
Explanation
A. The child: The primary focus of the physical examination is the child’s current health status, including assessment of all body systems. The examination aims to identify any deviations from normal growth, development, or function, and to correlate findings with the history provided.
B. The parents: While parents provide essential information regarding the child’s health, behaviors, and history, they are not the focus of the physical examination. Their role is to assist with history-taking and contextual information.
C. Chief complaint: The chief complaint guides the assessment and helps prioritize certain systems, but a comprehensive physical examination should extend beyond the presenting problem to evaluate overall health and detect any additional issues.
D. Developmental age: Assessing developmental age is part of the examination to compare expected growth and milestones with chronological age, but it is one component rather than the central focus, which remains the child’s overall physical condition.
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