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 A
Explanation
Rationale:
A. Mood swings are a common side effect of prednisone and indicate an understanding of the potential adverse effects.
B. Routine blood tests are not typically required for children on maintenance prednisone therapy for asthma.
C. Prednisone should not be withheld before physical activity, as it is a maintenance medication for asthma.
D. Decreased appetite is a common side effect of prednisone but is not the best indicator of understanding the teaching.
Correct Answer is B
Explanation
Rationale:
A. This is not a common adverse effect associated with morphine.
B. Nausea is a common adverse effect of morphine and should be monitored for, particularly in pediatric patients.
C. Stevens-Johnson syndrome is a severe allergic reaction and is not typically associated with morphine.
D. While morphine can cause urinary retention, it is not typically associated with renal failure.
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