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 B
Explanation
A. "You should notify your provider if your testes are firm and egg shaped." This statement does not provide specific guidance on when or how to perform the examination. It also describes a normal shape of the testes.
B. This is the correct statement. Performing the testicular self-examination following a warm shower helps relax the scrotal tissue, making it easier to detect any abnormalities or changes.
C. "If you feel a hard lump, wait 1 month and retest yourself." This is not advisable. If a hard lump is detected during a testicular self-examination, the individual should promptly notify their healthcare provider for further evaluation.
D. "You should perform the examination once every other month." While regular
testicular self-examinations are important, it is generally recommended to perform them monthly, not once every other month.
Correct Answer is B
Explanation
A. An upper respiratory infection 2 days ago is not a contraindication for the MMR vaccine. The vaccine can be administered once the child has recovered from the acute illness.
B. Correct. An allergy to neomycin, which is an antibiotic, is a contraindication for
receiving the MMR vaccine. Neomycin is present in trace amounts in the MMR vaccine, and individuals with a severe allergy to this antibiotic should not receive the vaccine.
C. A temperature of 37.2° C (99° F) is a low-grade fever and is not a contraindication for the MMR vaccine. Mild illness without fever is not a contraindication.
D. A family history of seizures is not a contraindication for the MMR vaccine. The vaccine can be safely administered to children with a family history of seizures.
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