A nurse is caring for a child post-operative tonsillectomy, what is the nursing priority when providing post-operative care?
Administer codeine postoperatively for pain management.
Offer the child a straw to drink fluids more easily.
Encourage the child to blow their nose gently to clear any mucus or secretions.
Monitor for evidence of bleeding, such as frequent swallowing or bright red emesis.
The Correct Answer is D
A. Although pain management is an important aspect of post-operative care, opioid use such as codeine is generally avoided in children due to the risk of respiratory depression and other side effects. Non- opioid pain relievers are preferred for post-tonsillectomy care.
B. While it is important for the child to stay hydrated after a tonsillectomy, using a straw can increase the risk of trauma to the surgical site, leading to bleeding. The nurse should encourage sipping liquids carefully without using a straw.
C. Blowing the nose after a tonsillectomy can cause pressure that may disrupt the healing tissue, increasing the risk of bleeding. This action should be avoided in the post-operative period.
D. Bleeding is a significant concern after a tonsillectomy, especially in the first 24 hours. Frequent swallowing may indicate that the child is swallowing blood, and bright red emesis (vomiting) may also signal active bleeding. Monitoring for signs of bleeding is the nursing priority, as it can be life- threatening if not addressed promptly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E","F"]
Explanation
A. Encouraging vigorous physical activity is not appropriate for an infant with RSV, as it can worsen respiratory distress.
B. Antibiotics are not effective against RSV because it is a viral infection. Antibiotics should only be used for secondary bacterial infections.
C. Isolation is crucial to prevent the spread of RSV to other infants, especially in healthcare settings.
D. Bronchodilators may be used to help open the airways and ease breathing in some cases of RSV.
E. Small, frequent feedings are important to prevent dehydration, as infants with RSV may struggle with feeding due to difficulty breathing.
F. Oxygen therapy is often required to maintain adequate oxygen levels in infants with RSV, particularly if they are experiencing respiratory distress.
Correct Answer is A
Explanation
A. Pain is a common and distressing symptom in children with otitis media. Assessing and managing the
child’s pain should be a priority.
B. While assessing vision can be important in some conditions, it is not a priority for recurrent otitis media.
C. Assessing lung sounds is important for respiratory assessments but not as relevant for otitis media.
D. Blood pressure assessment is not specifically indicated for otitis media unless there are other concerns.
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