A nurse is caring for a preschool-age child who is postoperative following a tonsillectomy and is clearing her throat frequently. Which of the following actions should the nurse take first?
Observe the child's throat with a flashlight.
Give the child small sips of water.
Administer an analgesic.
Offer the child an ice collar.
The Correct Answer is A
Rationale:
A. Observing the child's throat with a flashlight is necessary to detect any bleeding.
B. Giving the child small sips of water helps soothe the throat and promote hydration but it does not address the risk of bleeding as a complication of tonsillectomy.
C. Administering an analgesic may be indicated if the child is experiencing pain, but the throat should be assessed for any bleeding first.
D. Offering the child an ice collar may provide comfort, but assessing the throat for any bleeding is more essential.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Washing the child's hair with ketoconazole shampoo is not typically indicated for treating scabies, which is caused by mites.
B. Treating close contacts is essential to prevent the spread of scabies.
C. Applying petroleum jelly is not an effective treatment for scabies.
D. Soaking combs and brushes in boiling water may help to disinfect them but is not the primary treatment for scabies.
Correct Answer is []
Explanation
Correct Answers:
Condition Most Likely Experiencing: C
Actions to Take: A, B
Parameters to Monitor: B, C
Rationale:
Condition Most Likely Experiencing
A. Pyloric stenosis causes projectile vomiting, dehydration, and hunger.
B. Cystic fibrosis causes chronic respiratory infections, steatorrhea, and failure to thrive.
C. The condition that the infant is most likely experiencing is congestive heart failure, which can cause poor weight gain, tachypnea, decreased appetite, and periorbital edema.
D. Respiratory syncytial virus bronchiolitis causes wheezing, coughing, and respiratory distress.
Actions to Take
A. Elevating the head of the bed can help reduce the workload of the heart and improve breathing.
B. Digoxin can increase the contractility of the heart and decrease the heart rate.
C. Contact precautions are not indicated for congestive heart failure, but for infections that are transmitted by direct or indirect contact.
D. Chest physiotherapy and postural drainage are not indicated for congestive heart failure, but for conditions that cause excessive mucus production and retention.
Parameters to Monitor
A. Number of steatorrhea stools is not relevant for congestive heart failure, but for cystic fibrosis or other malabsorption disorders.
B. Intake and output can indicate fluid balance and renal function.
C. Respiratory status can reflect cardiac function and oxygenation.
D. Presence of periorbital edema is not a parameter to monitor, but a sign of fluid overload.
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