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 C
Explanation
A. Wrist restraints might not be appropriate for a very young infant as they may not adequately prevent the infant from reaching the mouth.
B. Jacket restraints are generally used for older children and are not appropriate for very young infants.
C. Elbow restraints are typically used for infants following oral surgeries to prevent them from putting their hands to their mouth, which is important in the case of cleft lip and palate repairs.
D. Mummy restraints are more commonly used for procedural immobilization rather than for postoperative care.
Correct Answer is A
Explanation
A. Acetaminophen is appropriate for managing mild discomfort post-procedure.
B. Tub baths are generally avoided for the first few days to prevent infection at the catheterization site; sponge baths are preferred.
C. Keeping the child home for 1 week might be excessive; follow the healthcare provider's specific instructions regarding activity and school return.
D. Clear liquids are typically offered as tolerated, but the primary concern post-procedure is monitoring the insertion site and ensuring the child rests adequately.
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