A nurse in a PACU is admitting a client who is postoperative following a tonsillectomy.
Which of the following actions should the nurse plan to take to prevent aspiration?

Suction the nasopharynx as needed.

Withhold fluids until the client demonstrates a gag reflex.

Perform chest physiotherapy.

Place a bedside humidifier at the head of the client's bed.

Answer and Explanation

The Correct Answer is B

A. Suctioning the nasopharynx as needed can help maintain airway patency but does not directly prevent aspiration during the recovery period.

B. Withholding fluids until the client demonstrates a gag reflex is a standard precaution to prevent aspiration, particularly in the immediate postoperative period.

C. Chest physiotherapy is not specifically indicated for preventing aspiration in the post- tonsillectomy period.

D. Placing a bedside humidifier at the head of the client's bed is not a specific intervention for preventing aspiration after tonsillectomy. Monitoring the client's ability to swallow and the return of the gag reflex is more relevant.

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Correct Answer is D

Explanation

A. Discouraging visits from friends may contribute to social isolation, which can negatively

impact the child's psychosocial well-being. Encouraging social interactions, when appropriate, is generally beneficial.

B. While play therapy may be useful in certain situations, it may not be the primary focus for a 10-year-old child. Encouraging age-appropriate activities and interactions, including school work, is important.

C. Varying the child's schedule each day might introduce unnecessary stress and disrupt the sense of routine and stability, which is essential for psychosocial well-being.

D. Encouraging the client to complete school work is aligned with Erikson's psychosocial stage of industry vs. inferiority. This stage emphasizes the importance of developing competence and skills, including academic achievements, during the school-age years. Supporting the child's educational needs is crucial for positive psychosocial development.

A. Collect all urine. B. Contact precautions. C. Do not palpate abdomen. D. No venipuncture or blood pressure in left arm.

Correct Answer is C

Explanation

A. Collecting all urine may be a part of the diagnostic process, but it is not the primary warning associated with Wilms' tumor.

B. Contact precautions are not typically required for Wilms' tumor.

C. The warning "Do not palpate abdomen" is crucial because palpation can potentially disrupt the tumor and cause hemorrhage.

D. No venipuncture or blood pressure in the left arm is not a typical precaution associated with Wilms' tumor. The emphasis is on avoiding abdominal palpation to prevent trauma to the tumor.

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A nurse in a PACU is admitting a client who is postoperative following a tonsillectomy. Which of the following actions should the nurse plan to take to prevent aspiration?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a 10-year-old child who will be hospitalized for an extended period of time. Which of the following actions should the nurse include in the plan of care to meet the client's psychosocial needs according to Erikson?

Correct Answer is D

Explanation

A child is admitted with a suspected diagnosis of Wilms’ tumor. The nurse should place a sign with which of the following warnings over the child’s bed?

Correct Answer is C

Explanation

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A nurse is caring for a 2-year-old child who is hospitalized and throws a tantrum when his parent leaves. Which of the following toys should the nurse provide to alleviate the child’s stress?

A nurse is caring for a child who is 2 hr postoperative following a tonsillectomy. Which of the following fluid items should the nurse offer the child at this time?

A nurse in a PACU is admitting a client who is postoperative following a tonsillectomy.
Which of the following actions should the nurse plan to take to prevent aspiration?