Respiratory Disorders - Tonsillitis/Epiglottitis Flashcards
Respiratory Disorders - Tonsillitis (Saunders NCLEX-PN Review Ch. 31)
- After a tonsillectomy, the child begins to vomit bright red blood. The initial nursing action would be to:
A. Turn the child to the side.
B. Notify the RN.
C. Administer the prescribed antiemetic.
D. Maintain NPO status.
A. Turn the child to the side.
Test-Testing Strategy:
Note the word “initial”. Although all of the options may be appropriate, to maintain physiological integrity, the initial action is to turn the child to the side.
Respiratory Disorders - Tonsillitis (Saunders NCLEX-PN Review Ch. 31)
- The appropriate child position after a tonsillectomy is which of the following?
A. Supine position
B. Side-lying position
C. High Fowler’s position
D. Trendelenburg’s position
B. Side-lying position
Rationale:
The child should be placed in a prone or side-lying position after tonsillectomy to facilitate drainage. Options A, C, and D will not achieve this goal.
Respiratory Disorders - Tonsillitis (Saunders NCLEX-PN Review Ch. 31)
- After a tonsillectomy, which of the following fluid or food items would be appropriate to offer to the child?
A. Yellow Jell-O
B. Cold ginger ale
C. Vanilla pudding
D. Cool cherry Kool-Aid
A. Yellow Jell-O
Rationale:
After a tonsillectomy, clear, cool liquids should be administered. Citrus, carbonated, and extremely hot or cold liquids needs to be avoided, because they may irritate the throat. Red liquids need to be avoided, because they give the appearance of blood if the child vomits. Milk and milk products (pudding)are avoided, because they coat the throat and cause the child to clear the throat, thus increasing the risk of bleeding.
Respiratory Disorders - Tonsillitis (Burke Textbook - Chapter 22)
To most effectively anticipate the needs of a client who has undergone a tonsillectomy, the nurse would plan to:
A. Apply a warm compress to the neck.
B. Place the client in a supine position.
C. Remove the nasopharyngeal airway immediately.
D. place a humidifier by the bedside.
D. place a humidifier by the bedside.
Rationale:
Moist air helps to loosen secretions and provide comfort for the postoperative tonsillectomy client. Ice collars are used to decrease the potential for hemorrhage. The HOB should be elevated with the client’s head turned to the side to facilitate drainage. The airway device must remain in place until the gag reflex returns.
Respiratory Disorders - Epiglottis (Saunders NCLEX-PN Review - Ch. 31)
- A nurse who is working in the emergency department is caring for a child who has been diagnosed with epiglottitis. Indications that the child ay be experiencing airway obstruction include which of the following?
A. Nasal flaring and bradycardia.
B. The child thrusts the chin forward and opens the mouth.
C. A low grade fever and complaints of a sore throat.
D. The child leans backward, supporting him- or herself with the hands and arms.
B. The child thrusts the chin forward and opens the mouth.
Rationale:
Clinical manifestations are suggestive of airway obstruction include tripod positioning (leaning forward supported by hands and arms with the chin thrust out and the mouth open), nasal flaring, tachycardia, and a high fever, and a sore throat.
Test-Taking Strategy:
Eliminate Option A first, because tachycardia rather than bradycardia will occur in a child experiencing respiratory distress. Eliminate Option C next, knowing that a high fever occurs with epiglottitis. From the remaining options, visualize the descriptions given in each, and determine which position would best assist a child who is experiencing respiratory distress.
Respiratory Disorders - Epiglottis (ATI Nursing Care of Children Ch. 16)
A nurse is assessing a child who may have bacterial epiglottitis. Which of the following manifestations is likely to be present? (Select all that apply.)
A. Hoarseness when speaking B. Difficulty swallowing C. Low-grade fever D. Drooling E. Stridor
A. Hoarseness when speaking
B. Difficulty swallowing
D. Drooling
E. Stridor
Rationale:
A child who is ill with epiglottitis typically exhibits dysphonia (hoarseness or difficulty speaking), dysphagia (difficulty swallowing), drooling, and anxiety with respiratory distress. Inspiratory stridor (noisy inspirations) is also common. The child usually has a high fever and a cough is not present
Respiratory Disorders - Tonsillitis (Maternal-Child (Towle) Textbook - Chapter 22)
A 5-year old had a tonsillectomy yesterday. The nurse would be LEAST concerned by:
A. halitosis.
B. increased pulse.
C. restlessness.
D. crying.
A. halitosis.
Respiratory Disorders - Tonsillitis (Maternal-Child (Towle) Textbook - Chapter 22)
The second day after a tonsillectomy, a child is receiving a full liquid diet. Which should be avoided?
A. popsicles
B. jello
C. vanilla pudding
D. orange juice
D. orange juice
Respiratory Disorders - Tonsillitis (Maternal-Child (Towle) Textbook - Chapter 22)
A toddler is being admitted to the pediatric unit with a diagnosis of epiglottitis. In planning care for this child, the nurse should:
A. notify the respiratory therapist of the admission.
B. have tracheostomy equipment available.
C. make the child NPO.
D. have antibiotics prepared when the child is admitted.
B. have tracheostomy equipment available.
Rationale:
Epiglottitis can result in airway obstruction. Anticipating this possible emergency situation , the nurse should plan ahead and have tracheostomy equipment available.
