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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Neck vein distention is not typically associated with acute acetylsalicylic acid poisoning.
B. Polyuria is not a common symptom of acute acetylsalicylic acid poisoning.
C. Jaundice is not typically associated with acute acetylsalicylic acid poisoning.
D. Hyperpyrexia (extremely high fever) is a potential complication of acute acetylsalicylic acid poisoning due to its effects on the central nervous system and metabolism.
Correct Answer is C
Explanation
Rationale:
A. Nuchal rigidity when standing may indicate meningitis, but it is not a common complication of lumbar puncture itself.
B. Double vision is not a typical complication of lumbar puncture and suggests other neurological issues.
C. Headache is a common complication of lumbar puncture, occurring due to leakage of cerebrospinal fluid (CSF) from the puncture site. It is often described as positional, worsening when the patient sits or stands upright and improving when lying down.
D. Pain in the posterior iliac crest is not a typical complication of lumbar puncture and may indicate musculoskeletal issues unrelated to the procedure.
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