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 B
Explanation
A. Relaxation: Relaxation techniques involve slowing breathing, loosening muscles, and promoting calmness to reduce pain perception, rather than diverting attention through humor or activities.
B. Distraction: Distraction involves redirecting the patient’s focus away from the painful stimulus. Using humor or engaging the patient in conversation or activities shifts attention, which can reduce the perception of pain during procedures.
C. Imagery: Imagery requires the patient to visualize pleasant or calming scenarios to manage pain, which is an internal cognitive process rather than an external distraction like telling a joke.
D. Thought stopping: Thought stopping involves teaching the patient to consciously interrupt negative or painful thoughts. Telling a joke does not involve actively stopping thoughts but instead diverts attention externally.
Correct Answer is C
Explanation
A. Rash on face: While some rashes may accompany infections, a localized facial rash in a neonate is nonspecific and can result from benign conditions such as erythema toxicum neonatorum, making it less indicative of systemic sepsis.
B. Edematous neck: Neck edema is uncommon in neonates and may suggest local trauma, lymphatic obstruction, or congenital anomalies rather than sepsis. It does not provide reliable evidence of systemic infection.
C. Hypothermia: Neonates with sepsis often present with hypothermia rather than fever due to immature thermoregulatory and immune systems. Persistent low body temperature, along with other signs such as lethargy or poor feeding, is a strong indicator of potential sepsis and warrants prompt evaluation and intervention.
D. Coughing: Coughing may indicate a respiratory condition, but isolated coughing is not a sensitive or specific marker for neonatal sepsis. Respiratory distress in combination with systemic signs would be more concerning.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.