NCLEX Secrets - Level of Cognitive Ability
41. A physician prescribes home health nurse visits for a child discharged with Reye's syndrome. During a home visit, a nurse instructs the parents about the residual effects of Reye's syndrome. Which statement, if made by the parents, indicates a need for further instruction?
a) we need to check for jaundiced skin and eyes everyday
b) we need to have the child nap during the day to provide rest
c) we need to decrease the stimuli at home to prevent increased intracranial pressure
d) we need to give frequent, small, nutritious meals to decrease the amount of vomiting
42. A nurse is reviewing the laboratory results for a child scheduled for tonsillectomy. The nurse determines that which laboratory value is most significant to review?
a) creatinine
b) prothrombin
c) sedimentation rate
d) blood urea nitrogen level
43. A child is scheduled for a tonsillectomy. A nurse plans care, knowing that which of the following would present the highest risk of aspiration during surgery?
a) difficulty in swallowing
b) bleeding during surgery
c) exudate in the throat area
d) presence of loose teeth
44. After a tonsillectomy, a nurse reviews the physician's postoperative orders. Which of the following physician's orders does the nurse question?
a) monitor for bleeding
b) suction every 2 hours
c) give no milk or milk products
d) give clear, cool liquids when awake
45. A nurse is caring for a child after a tonsillectomy. The nurse monitors the child, knowing that which of the following indicates that the child is bleeding?
a) frequent swallowing
b) a decreased pulse rate
c) complaints of discomfort
d) an elevation in blood pressure
NCLEX Secrets - Level of Cognitive Ability:
ANSWERS AND RATIONALE
41) D
- the vomiting that occurs in Reye's syndrome is caused by cerebral edema and is a symptom of increased intracranial pressure. Small frequent feeding will not affect the amount of vomiting, but, if vomiting occurs, the parents should contact the health care provider. Options A, B, and C are correct. Decreasing stimuli and providing rest decrease stress on the brain tissue. Checking for jaundice will assist in identifying the presence of liver dysfunction that occurs in Reye's syndrome.
42) B
- Because the tonsillar area is so vascular, postoperative bleeding is a concern. The prothrombin time, partial thromboplastin time, platelet count, hemoglobin and hematocrit, white blood cell count, and urinalysis are performed preoperatively. The prothrombin time results would identify a potential for bleeding. The creatinine level, sedimentation rate, and blood urea nitrogen would not determine the potential for bleeding.
43) D
- In the preoperative period, the child should be observed for the presence of loose teeth to decrease the risk of aspiration during surgery. Options 1 and 3 are incorrect because these are characteristics that may indicate the need for the surgery. Bleeding during surgery will be controlled via packing and suction as needed.
44) B
- After tonsillectomy, suction equipment should be available, but suctioning is not performed unless there is an airway obstruction because of the risk of trauma to the oropharynx. Monitoring for bleeding is an important nursing intervention following any type of surgery. Milk and milk products are avoided initially because they coat the throat, cause the child to clear the throat, and increase the risk of bleeding. Clear, cool liquids are encouraged.
45) A
- Frequent swallowing, restlessness, a fast and thready pulse, and vomiting bright red blood are signs of bleeding. An elevated blood pressure and complaints of discomfort are not indications of bleeding.
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