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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This statement indicates understanding. Giving water after administering digoxin helps ensure that the medication is swallowed and reaches the stomach, which is important for proper absorption.
B. Giving digoxin with foods high in fiber is not a specific instruction for administering this medication. It is important to follow the healthcare provider's specific dosing
instructions.
C. If a child vomits after taking digoxin, the parent should not give another dose. They should wait until the next scheduled dose. Double dosing can lead to overdose.
D. Mixing digoxin with juice is not recommended, as it may affect the absorption of the medication. It is best to give digoxin with a small amount of water.
Correct Answer is C
Explanation
A. Hypertension is not a typical finding in severe dehydration. In fact, dehydration often leads to decreased blood pressure.
B. Increased urine output is not a typical finding in severe dehydration. Dehydration leads to decreased urine output as the body tries to conserve fluids.
C. This is the correct answer. In severe dehydration, the body compensates by increasing the respiratory rate to try to maintain oxygen levels and remove excess carbon dioxide. This is a compensatory mechanism in response to metabolic acidosis, which can occur with dehydration.
D. A capillary refill of 2 seconds indicates normal perfusion. In severe dehydration, capillary refill may be prolonged, indicating poor perfusion.
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