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NO.1 A 5-year-old has just had a tonsillectomy and adenoidectomy. Which of these nursing measures
should be included in the postoperative care?
A. Have child gargle and do toothbrushing to remove old blood.
B. Encourage the child to cough up blood if present.
C. Give warm clear liquids when fully alert.
D. Observe for evidence of bleeding.
Answer: D
Explanation:
(A) The nurse should discourage the child from coughing, clearing the throat, or putting objects in his
mouth. These may induce bleeding. (B) Cool, clear liquids may be given when child is fully alert.
Warm liquids may dislodge a blood clot. The nurse should avoid red- or brown-colored liquids to
distinguish fresh or old blood from ingested liquid should the child vomit. (C) Gargles and vigorous
toothbrushing could initiate bleeding. (D) Postoperative hemorrhage, though unusual, may occur.
The nurse should observe for bleeding by looking directly into the throat and for vomiting of bright
red blood, continuous swallowing, and changes in vital signs.

NO.2 A woman diagnosed with multiple sclerosis is disturbed with diplopia. The nurse will teach her
to:
A. Limit activities which require focusing (close vision)
B. Take more frequent naps
C. Use artificial tears
D. Wear a patch over one eye
Answer: D
Explanation:
(A)
Limiting activities requiring close vision will not alleviate the discomfort of double vision.
(B)
Frequent naps may be comforting, but they will not prevent double vision. (C) Artificial tears are
necessary in the absence of a corneal reflex, but they have no effect on diplopia.
(D)
An eye patch over either eye will eliminate the effects of double vision during the time the eye patch
is worn. An eye patch is safe for a person with an intact corneal reflex.

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