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 ["2.0"]
Explanation
To calculate the dosage, follow these steps:
Step 1: Identify the prescribed dose.
The prescribed dose is 25 mg.
Result: 25 mg.
Step 2: Identify the concentration of the medication.
The concentration is 12.5 mg/mL.
Result: 12.5 mg/mL.
Step 3: Calculate the volume to administer.
Volume (mL) = (Prescribed dose in mg) ÷ (Concentration in mg/mL).
Volume (mL) = 25 mg ÷ 12.5 mg/mL.
Volume (mL) = 2 mL.
Result: 2 mL.
So, the nurse should administer 2.0 mL of diphenhydramine elixir per dose.
Correct Answer is B
Explanation
Choice A reason: The Health Care Proxy Does Not Go Into Effect Until I Am Incapable of Making Decisions
This statement is correct. A health care proxy, also known as a durable power of attorney for health care, only becomes active when the individual is no longer capable of making their own medical decisions. Until that point, the individual retains full control over their health care choices1.
Choice B reason: I Have to Choose a Family Member as My Health Proxy
This statement indicates a need for clarification. It is not necessary to choose a family member as a health care proxy. An individual can select any trusted person, whether a family member or a friend, to act as their health care proxy. The most important factor is that the chosen person understands the individual’s wishes and is willing to advocate for them2.
Choice C reason: I Can Change Who I Designate as My Health Care Proxy at Any Time
This statement is correct. An individual can change their designated health care proxy at any time, as long as they are still capable of making their own decisions. It is important to ensure that any changes are documented properly and that all relevant parties are informed of the change3.
Choice D reason: If I Become Incapacitated, End-of-Life Choices Will Be Made by My Proxy
This statement is correct. If an individual becomes incapacitated and is unable to make their own medical decisions, the health care proxy will step in to make decisions on their behalf, including end-of-life choices. The proxy should be well-informed about the individual’s preferences and values to make decisions that align with their wishes4.
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