A 5-year-old client is admitted for a tonsillectomy with adenoidectomy. What is the most important question for a nurse to ask while preparing the client for surgery?

"Does the child have a sore throat currently?”.

"Do the caregivers have soft foods at home for the child?”.

"When was the last time the child ate or drank anything?”.

"Does the child have any questions about the procedure?".

Answer and Explanation

The Correct Answer is C

Choice A rationale:

"Does the child have a sore throat currently?”. This choice is important but not the most critical question. The surgery involves tonsillectomy and adenoidectomy, so the child's current sore throat might not be as pertinent as other factors.

Choice B rationale:

"Do the caregivers have soft foods at home for the child?”. This choice is important for post-operative care, but the most crucial consideration is the child's fasting status before surgery.

Choice C rationale:

"When was the last time the child ate or drank anything?”. This choice is correct. It is essential to determine the child's fasting status before surgery to prevent potential complications related to anesthesia and surgery.

Choice D rationale:

"Does the child have any questions about the procedure?”. While ensuring the child's understanding is important, it is not the most critical question regarding preparation for the surgery.

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Correct Answer is B

Explanation

Minimize crying.

Choice A rationale:

Encouraging attachment might be important for the child's emotional well-being, but in the immediate postoperative period after cleft lip repair, minimizing crying takes priority. Crying can place stress on the suture line and disrupt the healing process.

Choice B rationale:

Minimizing crying is crucial to prevent tension on the suture line and ensure proper healing of the cleft lip repair. Excessive crying can lead to increased pressure on the surgical site and potential complications. Elbow restraints are applied to prevent the child from touching the surgical site, so minimizing crying helps to maintain the effectiveness of these restraints.

Choice C rationale:

Restricting oral intake is not a priority in this case. While it's important to ensure the child doesn't consume anything that might harm the surgical site, it's not the highest priority action compared to preventing tension on the suture line.

Choice D rationale:

Initiating range of motion is not the priority postoperative intervention for a cleft lip repair. The primary concern at this stage is to prevent disruption of the surgical site and ensure proper healing, making minimizing crying a higher priority.

A. Obtaining an order to have an indwelling urinary catheter inserted. B. Weighing the patient's wet diapers prior to discarding them. C. Sitting the patient on the bedpan at least every two hours. D. Applying a pediatric urine collection device over the patient's urinary meatus.

Correct Answer is B

Explanation

Weighing the patient's wet diapers prior to discarding them.

Choice A rationale:

Inserting an indwelling urinary catheter is invasive and not appropriate for a non-toilet-trained 2-year-old unless medically necessary.

Choice B rationale:

Weighing wet diapers is the most accurate way to measure urine output in a young child who isn't toilet trained. This method provides essential information for assessing hydration and kidney function.

Choice C rationale:

Sitting the patient on the bedpan every two hours is suitable for older children but may not be effective or tolerable for a 2-year-old.

Choice D rationale:

Applying a pediatric urine collection device is an option, but it might not be as accurate as weighing wet diapers and may cause discomfort for the child.

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A 5-year-old client is admitted for a tonsillectomy with adenoidectomy. What is the most important question for a nurse to ask while preparing the client for surgery?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is transferred to the pediatric unit after repair of a cleft lip. The child has a Logan bow in place over the suture line and has elbow restraints applied to both arms. Which nursing intervention should take priority in her postoperative care plan?

Correct Answer is B

Explanation

The nurse is to record the intake and output of a 2-year-old patient. The patient is not toilet trained. Which measure would be most appropriate to include in the patient's plan of care?

Correct Answer is B

Explanation

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