A nurse in a PACU is caring for a school-age child immediately following a tonsillectomy.
Which of the following actions should the nurse take?
Encourage the child to deep breathe and cough.
Offer the child ice cream when alert.
Instruct the child to drink fluids through a straw.
Place the child in a side-lying position.
The Correct Answer is D
After a tonsillectomy surgery, it is important to place the child in a side-lying position to help keep their airway open and prevent aspiration 1.
Choice A is wrong because deep breathing and coughing may cause discomfort and bleeding after a tonsillectomy.
Choice B is wrong because while ice cream may be soothing for the throat, it is not the only food that can be offered when the child is alert.
Choice C is wrong because drinking fluids through a straw may cause discomfort and bleeding after a tonsillectomy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is d. Exhibits head lag when pulled to a sitting position.
Choice A: Unable to hold a bottle At around 6 months of age, some babies can hold their own bottle. This is not a concerning finding for a 5-month-old infant. Therefore, this is not the correct answer.
Choice B: Unable to roll from back to abdomen Rolling over often starts around 4-6 months, so it’s not unusual for a 5-month-old to still be developing this skill. Therefore, this is not the correct answer.
Choice C: Absent grasp reflex The grasp reflex is an involuntary movement that your baby starts making in utero and continues doing until around 6 months of age. The grasp reflex lasts until the baby is about 5 to 6 months old. Therefore, this is not the correct answer.
Choice D: Exhibits head lag when pulled to a sitting position By the age of 5 months, most infants have developed enough strength in their neck and upper body to control their head movement. This means they should not exhibit a significant head lag when pulled to a sitting position1. If this is not the case, it could indicate a delay in motor development or a potential neurological issue, which should be reported to the healthcare provider for further evaluation. Therefore, this is the correct answer.
Correct Answer is A
Explanation
The nurse should request verbal consent from the client for STI testing.
All 50 states and the District of Columbia explicitly allow minors to consent for their own STI services.
Choice B is wrong because it is not necessary to contact the client’s parents to obtain phone consent.
Choice C is wrong because it is not necessary to postpone the testing until the client’s parents are present.
Choice D is wrong because written consent is not required for STI testing.
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