The nurse notices that a child is spitting up small amounts of blood in the immediate postoperative period after a tonsillectomy. What would be the best intervention?
Notify the health care immediately.
Continue to assess for bleeding.
Suction the back of the throat.
Encourage the child to cough.
The Correct Answer is A
A. Notifying the healthcare provider immediately is the best intervention because spitting up blood post-tonsillectomy could indicate bleeding, which requires prompt medical evaluation and intervention.
B. While continuing to assess for bleeding is important, immediate notification of the healthcare provider takes precedence to address potential complications.
C. Suctioning the throat might be contraindicated and could increase the risk of further bleeding.
D. Encouraging coughing is not appropriate as it could increase bleeding risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Nausea and vomiting are more commonly associated with hyperglycemia, not hypoglycemia.
B. Shakiness is a common symptom of hypoglycemia, indicating that the parents understand the signs of low blood glucose levels.
C. The onset of hypoglycemia is typically rapid, not slow, which is why quick intervention is necessary.
D. Sweating is a common symptom of hypoglycemia, not hyperglycemia.
Correct Answer is A
Explanation
A. Recording an upper extremity blood pressure (in the arms) compared to a lower extremity blood pressure (in the legs) can help reveal coarctation of the aorta, as the condition often results in higher blood pressure in the upper body and lower pressure in the lower body.
B. Assessing for femoral pulses is important but may not reveal coarctation of the aorta unless there is significant obstruction.
C. Excessive crying is not a specific indicator of coarctation of the aorta.
D. While a cardiac murmur can be associated with various heart conditions, it is not the most definitive assessment for coarctation of the aorta.
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