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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?

A. Observe the child's throat with a flashlight.

Observing the child's throat with a flashlight is necessary to detect any bleeding.

B. Give the child small sips of water.

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. Administer an analgesic.

Administering an analgesic may be indicated if the child is experiencing pain, but the throat should be assessed for any bleeding first.

D. Offer the child an ice collar.

Offering the child an ice collar may provide comfort, but assessing the throat for any bleeding is more essential.

This question is an excerpt from Nurse Dive's nursing test bank - Ati Rn Paediatric Nursing 2023 Proctored Exam. Take the full exam now


Full Explanation

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.


Similar Questions

QUESTION
A nurse is assessing a child who has heart failure. Which of the following findings is a clinical manifestation associated with this diagnosis?

A. Tachypnea

Tachypnea (rapid breathing) is a common clinical manifestation of heart failure due to decreased cardiac output and inadequate tissue perfusion.

B. Tremors

Tremors are not typically associated with heart failure.

C. Increased appetite

Increased appetite is not typically associated with heart failure and may even be decreased due to symptoms such as fatigue and dyspnea.

D. Bradycardia

Bradycardia (slow heart rate) is not typically associated with heart failure; instead, tachycardia (rapid heart rate) may occur as a compensatory mechanism.

Full Explanation

Rationale:

A. Tachypnea (rapid breathing) is a common clinical manifestation of heart failure due to decreased cardiac output and inadequate tissue perfusion.

B. Tremors are not typically associated with heart failure.

C. Increased appetite is not typically associated with heart failure and may even be decreased due to symptoms such as fatigue and dyspnea.

D. Bradycardia (slow heart rate) is not typically associated with heart failure; instead, tachycardia (rapid heart rate) may occur as a compensatory mechanism.

QUESTION

A nurse is caring for a school-age child who has diabetes mellitus. Which of the following findings should the nurse recognize as being consistent with hyperglycemia?

A. Sweating

Sweating is more commonly associated with hypoglycemia (low blood sugar) rather than hyperglycemia (high blood sugar).

B. Tremors

Tremors are more commonly associated with hypoglycemia.

C. Pallor

Pallor is not typically associated with hyperglycemia.

D. Thirst

Thirst (polydipsia) is a classic symptom of hyperglycemia in diabetes mellitus, as the body tries to dilute the excess sugar in the bloodstream by increasing fluid intake.

Full Explanation

Rationale:

A. Sweating is more commonly associated with hypoglycemia (low blood sugar) rather than hyperglycemia (high blood sugar).

B. Tremors are more commonly associated with hypoglycemia.

C. Pallor is not typically associated with hyperglycemia.

D. Thirst (polydipsia) is a classic symptom of hyperglycemia in diabetes mellitus, as the body tries to dilute the excess sugar in the bloodstream by increasing fluid intake.

QUESTION
A nurse is caring for an 8-year-old child who was recently diagnosed with chronic renal failure. The child's parents ask for information on hemodialysis. Which of the following statements should the nurse make?

A. "Hemodialysis uses your child's abdominal cavity as a membrane to clean their blood."

This statement describes peritoneal dialysis, not hemodialysis.

B. "Hemodialysis uses an electrolyte solution to clean your child's blood."

Hemodialysis does not use an electrolyte solution to clean the blood.

C. "Hemodialysis uses an artificial membrane outside the body to clean your child's blood."

Hemodialysis indeed involves circulating the blood outside the body through an artificial membrane in the dialysis machine to remove waste products and excess fluids.

D. "Hemodialysis slowly filtrates your child's blood continuously."

Hemodialysis involves intermittent filtration of the blood, not continuous filtration.

Full Explanation

Rationale:

A. This statement describes peritoneal dialysis, not hemodialysis.

B. Hemodialysis does not use an electrolyte solution to clean the blood.

C. Hemodialysis indeed involves circulating the blood outside the body through an artificial membrane in the dialysis machine to remove waste products and excess fluids.

D. Hemodialysis involves intermittent filtration of the blood, not continuous filtration.