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 A
Explanation
Choice A reason:
The Heimlich maneuver, also known as abdominal thrusts, is the recommended first aid technique for a conscious person who is choking. This maneuver helps to expel the object blocking the airway by using the air remaining in the lungs to force it out. The nurse should stand behind the person, place their arms around the person’s waist, make a fist with one hand, and place it just above the navel. The other hand should grasp the fist, and quick, upward thrusts should be performed until the object is expelled.
Choice B reason:
Slapping the client on the back several times is not the recommended first action for a conscious adult who is choking. While back blows can be effective, they are typically used in combination with abdominal thrusts and are more commonly recommended for infants. For adults, the Heimlich maneuver is preferred as the initial response.
Choice C reason:
Assisting the client to the floor and beginning mouth-to-mouth resuscitation is not appropriate for a conscious person who is choking. Mouth-to-mouth resuscitation, or rescue breathing, is used when a person is not breathing and is unresponsive. In this scenario, the client is conscious but unable to speak, indicating a blocked airway that requires the Heimlich maneuver.
Choice D reason:
Observing the client before taking further action is not advisable in a choking emergency. Immediate intervention is crucial to prevent the situation from worsening. If the person is unable to speak, cough, or breathe, the Heimlich maneuver should be performed without delay.
Correct Answer is A
Explanation
Choice A reason: Generalized Urticaria
Generalized urticaria, or widespread hives, is a common sign of an allergic transfusion reaction. This reaction occurs when the recipient’s immune system reacts to proteins in the donor blood. Symptoms can range from mild, such as itching and hives, to severe, including anaphylaxis. Immediate intervention typically involves stopping the transfusion and administering antihistamines.
Choice B reason: Distended Jugular Veins
Distended jugular veins are not indicative of an allergic transfusion reaction. This finding is more commonly associated with conditions such as congestive heart failure or fluid overload. In the context of a blood transfusion, it could suggest circulatory overload rather than an allergic reaction.
Choice C reason: Blood Pressure 184/92 mm Hg
An elevated blood pressure reading, such as 184/92 mm Hg, is not specific to an allergic transfusion reaction. While blood pressure changes can occur during a transfusion, they are not a hallmark of an allergic response. This finding could be related to other factors, such as anxiety or pre-existing hypertension.
Choice D reason: Bilateral Flank Pain
Bilateral flank pain is not a typical symptom of an allergic transfusion reaction. This symptom is more commonly associated with hemolytic transfusion reactions, where the recipient’s immune system attacks the donor red blood cells, leading to hemolysis and subsequent kidney pain.
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