A nurse is reinforcing discharge instructions with a parent of a 6-year-old child who has just had a tonsillectomy. Which of the following statements by the parent indicates an understanding of postoperative care?
"It's okay for my child to have plenty of ice cream."
"I'll help my child gargle with salt water a few times a day."
"It's okay for my child to ride his bike in a few days."
"I'll call the doctor if my child is swallowing continuously."
The Correct Answer is D
A. ``It's okay for my child to have plenty of ice cream.": While ice cream is soft and soothing, it may increase mucus production. Dairy products are contraindicated post tonsillectomy.
B. "I'll help my child gargle with salt water a few times a day.": Gargling is contraindicated post-tonsillectomy because it can dislodge clots and increase the risk of bleeding.
C. "It's okay for my child to ride his bike in a few days.": Strenuous activity should be avoided to reduce the risk of bleeding.
D. "I'll call the doctor if my child is swallowing continuously.": Continuous swallowing can indicate bleeding, a serious complication that requires immediate medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Cyanosis with crying: Cyanosis is less common in isolated PDA and more indicative of other congenital heart defects. PDA usually results in increased pulmonary blood flow and may not directly cause cyanosis, especially in less severe cases.
B. Weak pulses: PDA typically causes increased pulmonary blood flow and can result in bounding pulses rather than weak ones. Weak pulses are more indicative of reduced cardiac output, which is not characteristic of PDA.
C. Chronic hypoxemia: Chronic hypoxemia is less associated with PDA and more common in cyanotic heart defects where oxygenated and deoxygenated blood mix. PDA primarily affects the volume of blood flow to the lungs and may not lead to hypoxemia unless complicated by other conditions.
D. Machine-like murmur: A characteristic feature of PDA is a continuous, machine-like murmur caused by turbulent blood flow between the aorta and the pulmonary artery. This murmur is a hallmark sign of PDA and is typically heard during auscultation.
Correct Answer is B
Explanation
A. Capillary refill less than 2 seconds: A capillary refill time of less than 2 seconds indicates good peripheral circulation, which is normal and not a cause for concern in this context. It is not the priority.
B. Tingling in the right foot Rationale: Tingling (paraesthesia) can be a sign of nerve damage or compromised circulation, which may indicate complications such as compartment syndrome. This is a priority finding because it can lead to severe consequences if not addressed promptly.
C. 2+ right pedal pulse Rationale: A 2+ pedal pulse indicates a normal pulse strength, which suggests that there is adequate blood flow to the extremity. It is not a priority compared to the potential for neurological or circulatory compromise.
D. Respiratory rate 24/min Rationale: A respiratory rate of 24/min is within the normal range for a school-age child (18-30 breaths per minute). While it is important to monitor vital signs, it is not a priority concern related to the fracture.
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