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.
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Related Questions
Correct Answer is D
Explanation
A. Positioning the infant on the abdomen is contraindicated after cleft lip repair because it could put pressure on the surgical site, risking injury or dehiscence.
B. Offering a pacifier is not advised as it could disrupt the surgical site and delay healing.
C. Ibuprofen is not typically recommended for infants younger than 6 months due to the risk of adverse effects; acetaminophen is usually preferred for pain management in this age group.
D. Encouraging the parents to rock the infant provides comfort and soothes the baby without risking harm to the surgical site. Parental involvement also helps with bonding and emotional support during recovery.
Correct Answer is C
Explanation
A. Glyburide is an oral hypoglycemic agent used for type 2 diabetes, not type 1 diabetes, which requires insulin therapy.
B. Insulin should be injected into the subcutaneous tissue, typically in areas such as the abdomen or thighs, not the deltoid muscle.
C. Annual influenza vaccination is important for adolescents with type 1 diabetes to prevent infections that can affect blood glucose control.
D. Glucagon is used to treat severe hypoglycemia, not hyperglycemia. For hyperglycemia, insulin adjustments are necessary.
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