The nurse is doing discharge teaching for a child who has had a tonsillectomy. The nurse tells the client and family that the child should have plenty of fluids. In addition, the nurse would explain to the child’s caregiver that the child may:
Be given ice cream and milk the first postoperative day because these foods make swallowing easier.
Have a painful earache around the third day postoperatively but the earache will be gone by the fourth day.
Vomit dark old blood but the caregiver should call the clinic if the child has bleeding between the fifth and seventh days postoperatively.
Have severe throat pain for up to 2 weeks postoperatively; this is not a concern.
The Correct Answer is C
Choice A reason: Ice cream and milk may coat the throat, increasing mucus and infection risk post-tonsillectomy. Vomiting dark blood is normal, but new bleeding requires attention, making this incorrect, as dairy is not recommended for easing swallowing in the immediate postoperative period for the child.
Choice B reason: Earache from referred pain is common post-tonsillectomy but may persist beyond the fourth day. Vomiting old blood with guidance on new bleeding is more accurate, making this incorrect, as it underestimates the duration and management of ear pain in the recovery period.
Choice C reason: Vomiting dark old blood is normal post-tonsillectomy due to swallowed blood, but fresh bleeding between days 5-7 indicates potential complications, requiring clinic contact. This aligns with pediatric postoperative care, making it the correct explanation for caregivers during discharge teaching for the child.
Choice D reason: Severe throat pain for 2 weeks is expected but should be monitored, not dismissed, as it may signal complications. Guidance on bleeding is more critical, making this incorrect, as it downplays the need for vigilance regarding pain in the postoperative recovery period.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Determining the chief complaint identifies the primary reason for the visit, guiding the assessment and care plan for the child. This aligns with pediatric nursing triage principles, making it the prioritized step to ensure focused, efficient care during the first visit to the clinic.
Choice B reason: Interviewing the caregiver provides context but follows identifying the chief complaint, which directs the conversation. The complaint sets the visit’s focus, making this secondary and incorrect compared to prioritizing the reason for the child’s visit in the initial pediatric clinic appointment.
Choice C reason: Obtaining biographical data is administrative and less urgent than addressing the child’s health concern. The chief complaint drives the clinical encounter, making this less critical and incorrect compared to prioritizing the identification of the primary issue in the first clinic visit.
Choice D reason: Recording the health history is important but comes after understanding the chief complaint, which shapes the history-taking. Identifying the complaint ensures relevance, making this subsequent and incorrect compared to the prioritized step of determining the reason for the child’s visit.
Correct Answer is B
Explanation
Choice A reason: Intravenous administration isn’t inherently safer, as it carries risks like infection or extravasation. Less trauma from fewer injections is accurate, making this incorrect, as it overstates safety compared to the true benefit of reduced physical and emotional trauma in pediatric IV medication delivery.
Choice B reason: Intravenous medication reduces the need for multiple injections, minimizing physical and emotional trauma for children. This aligns with pediatric nursing principles for patient comfort, making it the correct statement about the advantage of IV administration compared to repeated intramuscular or subcutaneous injections.
Choice C reason: IV medications are absorbed rapidly, not slowly, due to direct bloodstream delivery. Less trauma from fewer injections is the true benefit, making this incorrect, as it misrepresents the pharmacokinetics of intravenous administration in the context of pediatric medication delivery.
Choice D reason: IV medication is delivered into veins, not fatty tissue, which describes subcutaneous injections. Reduced trauma from fewer injections is accurate, making this incorrect, as it confuses IV administration with another route in the nurse’s understanding of medication delivery methods.
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