A nurse is caring for a toddler who is 24 hours postoperative following a cleft palate repair. Which of the following actions should the nurse take?
Apply bilateral wrist restraints.
Administer opioids for pain.
Implement a soft diet.
Offer fluids through a straw.
The Correct Answer is C
Choice A reason: Apply Bilateral Wrist Restraints
Applying bilateral wrist restraints can be necessary in some cases to prevent the child from touching or interfering with the surgical site. However, restraints should be used as a last resort and only when absolutely necessary. They can cause distress and discomfort to the child and should be monitored closely to prevent any complications.
Choice B reason: Administer Opioids for Pain
Administering opioids for pain management is a common practice post-surgery to ensure the child is comfortable. However, opioids should be used cautiously due to the risk of side effects and potential for dependency. Non-opioid pain management strategies, such as acetaminophen or ibuprofen, are often preferred unless the pain is severe.
Choice C reason: Implement a Soft Diet
Implementing a soft diet is crucial for a child who is 24 hours postoperative following a cleft palate repair. The surgical site in the mouth is still healing, and a soft diet helps prevent any damage or irritation to the area. Soft foods are easier to swallow and less likely to cause pain or disrupt the healing process. Examples of soft foods include mashed potatoes, yogurt, and pureed fruits.
Choice D reason: Offer Fluids Through a Straw
Offering fluids through a straw is not recommended for a child who has undergone cleft palate repair. The suction created by using a straw can put pressure on the surgical site and potentially cause complications. Instead, fluids should be offered using a cup or a spoon to minimize any risk to the healing palate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
Step 1: Determine the dosage required. Required dosage = 150 mg
Step 2: Determine the dosage available per tablet. Available dosage per tablet = 75 mg
Step 3: Calculate the number of tablets needed. Number of tablets needed = Required dosage ÷ Available dosage per tablet Number of tablets needed = 150 mg ÷ 75 mg
Step 4: Perform the division. 150 ÷ 75 = 2
The nurse should administer 2 tablets per dose.
Correct Answer is ["100"]
Explanation
Step 1: Identify the infusion rate in mL/hr.
- The infusion rate is 100 mL/hr.
- = 100 mL/hr.
Step 2: Determine the drop factor for microtubing.
- Microtubing has a drop factor of 60 gtt/mL.
- = 60 gtt/mL.
Step 3: Calculate the drip rate in gtt/min.
- Drip rate (gtt/min) = (Infusion rate in mL/hr) × (Drop factor in gtt/mL) ÷ 60.
- Drip rate (gtt/min) = 100 mL/hr × 60 gtt/mL ÷ 60.
- = 100 gtt/min.
So, the nurse should set the manual IV infusion to deliver 100 gtt/min.
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