The nurse is caring for a child who has just returned from surgery following a tonsillectomy and adenoidectomy. Which action by the nurse is appropriate?

Correct Answer: D

Rationale: Observing swallowing detects bleeding, a critical post-tonsillectomy concern.

Correct Answer: C

Rationale: Benztropine's anticholinergic effects worsen glaucoma and prostatic hypertrophy.

Correct Answer: D

Rationale: Regular mouth care is essential to maintain oral health, prevent infections, and ensure patient comfort, especially for those unable to perform it themselves. Brushing once a week is inadequate daily care is the standard to remove plaque and bacteria. A firm-bristled brush can damage gums, particularly in frail patients, so softer bristles are preferred. Vigorous flossing risks injuring sensitive tissues and isn't suitable for all patients, especially those with limited mobility or cooperation. Regular mouth care, tailored to the patient's needs (e.g., brushing, swabbing, or rinsing), prevents complications like gingivitis or aspiration pneumonia, which are risks in dependent patients. It's a proactive, gentle approach that prioritizes hygiene and safety.

Correct Answer: D

Rationale: Explaining the process and involving the patient as much as possible when making an occupied bed ensures safety by keeping them informed and stable during repositioning. This reduces anxiety, prevents sudden movements, and allows the nurse to adjust based on the patient's ability. Changing linens weekly compromises hygiene and comfort, risking skin issues. Raising all side rails might trap or confuse the patient, increasing fall risk if they try to move. Asking them to leave the bed defeats the 'occupied' purpose and isn't always feasible. Communication and collaboration minimize hazards, aligning with safe, patient-centered care principles.

Correct Answer: C

Rationale: A pressure-reducing mattress redistributes body weight to minimize pressure on bony prominences, reducing the risk of pressure ulcers in immobile patients. It enhances blood flow to vulnerable areas like the sacrum or heels, countering the effects of prolonged stillness. Elevating legs might occur with positioning but isn't the mattress's primary role. Exerting pressure for pain relief contradicts its purpose it relieves, not applies, pressure. Immobilizing during sleep isn't the goal; it's about protection, not restraint. Nurses rely on this tool as a proactive measure, complementing repositioning to maintain skin integrity in at-risk patients.