Health Promotion and Maintenance
57. A 7-year-old child is hospitalized for a tonsillectomy. What are priority nursing actions when caring for this child after surgery? Select all that apply.
Health Promotion and Maintenance
57. A 7-year-old child is hospitalized for a tonsillectomy. What are priority nursing actions when caring for this child after surgery? Select all that apply.
. Advancing diet as tolerated.
. Encouraging coughing to clear the throat.
. Monitoring PT and PTT.
. Administering pain medication around the clock.
. Suctioning mouth and throat frequently.
Test-Taking Tip
Consider that the surgical area for tonsillectomy is in the child's throat. Potential hemorrhage in this area could lead to serious respiratory compromise; therefore, priority nursing actions should be to monitor and protect the airway.
Content Area: Child Health, Respiratory; Integrated Process: Nursing Process, Planning; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Complications from Surgical Procedures and Health Alterations
Health Promotion and Maintenance
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Answer 1 is correct because, following tonsillectomy, the child may begin oral intake after surgery, beginning with ice chips and progressing as tolerated to avoid vomiting, which could injure the surgical site. Answer 2 is incorrect because coughing should be discouraged as this puts stress on the tonsillectomy site and causes bleeding. Answer 3 is correct because increased bleeding times put the child at risk for hemorrhage at the tonsillectomy site, which could compromise the airway. Answer 4 is correct because the nurse should expect that the child will have pain from the tonsillectomy. Pain control is best achieved with around-the-clock dosing. Without adequate pain control, the child may cry, putting stress on the surgical site. Answer 5 is incorrect because frequent oral suctioning puts stress on the tonsillectomy site and causes bleeding.