The nurse is providing discharge instructions to the parent of a patient who had a tonsillectomy/adenoidectomy. Which statement would indicate that the parent needs further teaching?
"We will return to the hospital if my child spits up blood.".
"I'll give my child cherry gelatin since that is her favorite.".
"We will return to the hospital if my child develops difficulty breathing.".
"I'll have my child rinse her mouth frequently with water to prevent a bad breath odor.".
The Correct Answer is B
Choice A rationale:
Returning to the hospital if the child spits up blood is a correct response as it indicates the recognition of potential postoperative bleeding.
Choice B rationale:
Giving the child cherry gelatin, even though it's the child's favorite, might not be appropriate after a tonsillectomy/adenoidectomy, as certain foods can irritate the healing throat.
Choice C rationale:
Returning to the hospital if the child develops difficulty breathing is a necessary step to address any respiratory distress.
Choice D rationale:
Having the child rinse her mouth frequently with water to prevent a bad breath odor is a suitable suggestion to maintain oral hygiene and comfort after surgery. In all three scenarios, the rationale for the correct answers revolves around patient safety, comfort, and appropriate post-operative care. The incorrect choices in each question either introduce potential complications, misunderstandings, or actions that might compromise the patient's well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B rationale:
After cleft palate repair, infants should be fed pureed or soft foods to prevent trauma to the surgical site and facilitate healing. These textures minimize the risk of injury and avoid strain on the repaired area.
Choice A rationale:
Allowing the child to self-feed with a spoon can introduce solid textures prematurely and pose a risk of disrupting the surgical repair.
Choice C rationale:
Using a cup with a straw might cause suction that could negatively impact the healing surgical site, increasing the risk of complications.
Choice D rationale:
Restricting breastfeeding is not necessary for cleft palate repair. However, positioning adjustments may be needed to facilitate effective breastfeeding while minimizing stress on the surgical area.
Correct Answer is C
Explanation
Reviewing the patient's complete blood count.
Choice A rationale:
Measuring height is not a priority when administering zidovudine.
Choice B rationale:
Monitoring weight gain is important but not the first priority.
Choice C rationale:
Reviewing the complete blood count is crucial before administering zidovudine, as this medication can cause bone marrow suppression. Checking for changes in white blood cell counts, hemoglobin, and platelet levels is essential to ensure the patient can tolerate the medication without severe adverse effects.
Choice D rationale:
Reviewing the patient's chemistry profile is relevant, but assessing blood counts is more critical due to zidovudine's potential impact on bone marrow function.
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