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. Hypotension is not typically associated with coarctation of the aorta; it more often leads to hypertension in the upper body.
B. Unequal pulses in the upper and lower extremities are a classic sign of coarctation of the aorta, as the obstruction typically affects blood flow to the lower body.
C. Excessive crying is not a specific indicator of coarctation of the aorta and can occur due to various reasons.
D. A diastolic murmur is not a primary indicator of coarctation of the aorta; it is more associated with other cardiac conditions.
Correct Answer is B
Explanation
A. Respiratory rate can be affected by many factors and is not the most reliable indicator of fluid loss.
B. Body weight is the most reliable indicator of fluid loss, as it directly reflects changes in body fluid levels.
C. Blood pressure changes can occur with fluid loss but may not be as sensitive or immediate as changes in body weight.
D. Skin integrity is important to monitor, but changes in body weight provide a more direct measure of fluid status.
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