A nurse is caring for a school age child who is 1 hour postoperative following a tonsillectomy.
Which of the following actions should the nurse take?
. Discourage the child from coughing
Provide cranberry juice to the child
Maintain the child in a supine position
Administer an analgesic to the child on a schedule basis
Correct Answer : A
The correct answer is choice a. Discourage the child from coughing.
Choice A rationale:
Discouraging the child from coughing is important because coughing can dislodge clots and cause bleeding at the surgical site, which is a common complication after a tonsillectomy.
Choice B rationale:
Providing cranberry juice to the child is not recommended because acidic juices can irritate the throat and cause discomfort or pain.
Choice C rationale:
Maintaining the child in a supine position is not ideal as it can increase the risk of aspiration. Instead, the child should be positioned on their side or with the head elevated to facilitate drainage and reduce the risk of aspiration.
Choice D rationale:
Administering an analgesic to the child on a scheduled basis is important for pain management, but it is not the most immediate action to take one hour postoperatively. Pain management should be part of the overall care plan.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Performing the examination once every other month is not the recommended frequency. It is generally recommended that males perform a testicular self-examination monthly.
Choice B rationale
Notifying your provider if your testes are firm and egg-shaped may not be necessary, as this is generally considered a normal characteristic of testes. However, any changes in size, shape, or consistency should be reported.
Choice C rationale
Waiting a month after feeling a hard lump is not recommended. If a hard lump is detected during a self-
examination, it should be reported to a healthcare provider immediately, as it could be a sign of testicular cancer.
Choice D rationale
Performing the examination following a warm shower is recommended. The warmth relaxes the scrotum, making it easier to examine the testicles.
Correct Answer is B
Explanation
Choice A rationale
A child’s weight being in the 45th percentile is within the normal range and is not in itself an indicator of physical abuse.
Choice B rationale
Bruising around the wrists can be a potential indicator of physical abuse. Unexplained bruises, particularly in unusual locations or in specific patterns, can be a sign of physical abuse.
Choice C rationale
Abrasions on the knees are common in children due to normal play and activity and are not typically an indicator of physical abuse.
Choice D rationale
Missing front deciduous teeth in a 7-year-old student is not typically an indicator of physical abuse. It is normal for children to begin losing their deciduous (baby) teeth around this age.
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