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.
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Related Questions
Correct Answer is A
Explanation
A. This statement demonstrates understanding. Elevating the broken arm on pillows can help reduce swelling and promote comfort during the night.
B. Limiting the use of the fingers of the broken arm is important for proper healing.
However, the client should still engage in gentle range-of-motion exercises as instructed by the healthcare provider.
C. Expecting some degree of swelling in the fingers is normal after the application of a cast. This statement shows understanding.
D. Sprinkling baby powder into the cast if the arm itches is not recommended. It can cause irritation and is not an effective way to address itching under the cast. The client should be instructed not to insert anything into the cast.
Correct Answer is B
Explanation
A. Starting the IV in the infant's foot is not the preferred site for a 12-month-old who is ambulatory or beginning to walk, as it can interfere with mobility. The hand, forearm, or scalp (if necessary) are preferred sites.
B. Using a 24-gauge catheter is the correct choice, as smaller-gauge catheters (24- to 26-gauge) are appropriate for infants to minimize trauma and facilitate proper IV access.
C. Changing the IV site every 3 days is a general guideline for adults, but in infants, the site should be assessed frequently and changed as needed based on signs of infiltration or complications.
D. Covering the insertion site with an opaque dressing is incorrect because a transparent dressing is preferred to allow for continuous assessment of the site for complications such as infiltration or phlebitis.
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