A nurse is caring for a school-age child who is 1 hr postoperative following a tonsillectomy.

Which of the following actions should the nurse take? (Select all that apply.)

Maintain the child in a supine position.

Provide cranberry juice to the child.

Discourage the child from coughing.

Administer an analgesic to the child on a scheduled basis.

Observe the child for frequent swallowing.

Answer and Explanation

Correct Answer : D,E

A. Maintaining the child in a supine position is not recommended after a tonsillectomy.
The child should be positioned on their side to prevent aspiration.

B. Cranberry juice is acidic and may be irritating to the surgical site. Clear, non-acidic fluids are usually recommended after a tonsillectomy.

C. While coughing should be minimized to prevent irritation to the surgical site, the child should not be discouraged from coughing if needed to clear secretions.

D. Administering an analgesic on a scheduled basis is important for managing pain after a tonsillectomy. This helps to maintain a consistent level of pain control.

E. Observing the child for frequent swallowing is important, as it may indicate bleeding or discomfort. This is a key assessment after a tonsillectomy.

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Correct Answer is C

Explanation

A. Placing the child in the Trendelenburg position is not necessary for tracheostomy care. In fact, this position is generally not recommended for routine tracheostomy care.

B. Sterile technique, not clean technique, should be used when changing the tracheostomy tube to reduce the risk of infection.

C. This is the correct action. Having the child flex his head can help prevent tension on the tracheostomy ties and ensure a secure and comfortable fit.

D. Full-strength hydrogen peroxide is too harsh and can cause irritation to the skin around the stoma. It is recommended to use normal saline or a mild soap and water solution for cleaning.

A. "I will have my child try to defecate 15 minutes after each meal." B. "I will limit my child's fluid intake." C. "I will have my child sit on the toilet for 20 minutes at a time." D. "I will increase my child's dairy intake."

Correct Answer is A

Explanation

A. This statement demonstrates an understanding of a helpful strategy for managing encopresis. Having the child try to defecate 15 minutes after each meal can take advantage of the body's natural reflexes and increase the likelihood of regular bowel movements.

B. Limiting fluid intake is not a recommended strategy for managing encopresis.
Maintaining proper hydration is important for overall health.

C. Having the child sit on the toilet for extended periods of time may lead to frustration and aversion to toilet training. It is not a recommended approach.

D. Increasing dairy intake is not a specific strategy for managing encopresis. In fact, some dairy products can contribute to constipation in some individuals. A balanced diet with an appropriate amount of fiber is important for bowel regularity.

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A nurse is caring for a school-age child who is 1 hr postoperative following a tonsillectomy. Which of the following actions should the nurse take? (Select all that apply.)

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Correct Answer is C

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Correct Answer is A

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A nurse is caring for a school-age child who is 1 hr postoperative following a tonsillectomy.

Which of the following actions should the nurse take? (Select all that apply.)