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. Capillary refill time of 3 seconds is within the normal range (less than 3 seconds) and does not indicate severe dehydration.
B. A sunken anterior fontanel is a significant sign of dehydration in infants and suggests severe dehydration.
C. While a weight loss of 5% can indicate dehydration, it may not necessarily represent severe dehydration. The extent of dehydration is better assessed by clinical signs such as fontanel status, skin turgor, and mucous membrane moisture.
D. Producing tears when crying is a reassuring sign and suggests adequate hydration, so it does not indicate severe dehydration.
Correct Answer is A
Explanation
Rationale:
A. Lavender oil is commonly used for relaxation and calming effects.
B. Eucalyptus oil is more commonly used for respiratory issues and may not be as suitable for relaxation.
C. Jasmine oil is often used for its pleasant scent but may not have the same relaxation properties as lavender.
D. Tea tree oil is typically used for its antimicrobial properties and may not be as effective for relaxation purposes as lavender.
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