The nurse is caring for a client.

Which of the following actions should the nurse take? Select all that apply.

Rationale for correct choices

• Inspect the child’s oropharynx: The child has bright red emesis and visible bleeding in the posterior pharynx, which indicates active post-tonsillectomy hemorrhage. Direct visualization helps confirm the bleeding source and severity. Early inspection supports rapid intervention because post-operative tonsillar bleeding can progress quickly and become life-threatening.

• Obtaining a set of vital signs: Active bleeding and vomiting bright red blood require immediate reassessment of vital signs to detect tachycardia, hypotension, or respiratory compromise. Hemoglobin and hematocrit are already low, increasing the child’s risk for hemodynamic instability. Timely vital signs guide urgent decisions about fluid resuscitation and notifying the provider.

Rationale for incorrect choices

• Offer the child a red popsicle: Providing red-colored fluids can mask ongoing bleeding and delay recognition of hemorrhage. The priority is to assess and stabilize the child with known bleeding, not to offer oral intake. This intervention risks obscuring the color of emesis or oral bleeding.

• Place the child in a supine position: Supine positioning increases the risk of aspiration when bleeding or vomiting is present. The child should be maintained upright to allow drainage and airway protection. Supine positioning does not address the current complication and may worsen respiratory safety.

• Encouraging the child to cough and deep breathe: Coughing can dislodge clots and worsen post-tonsillectomy bleeding. The child already has active bright red bleeding, so stimulating airway pressure would increase hemorrhage risk. This intervention is inappropriate in immediate postoperative bleeding scenarios.

• Requesting a prescription for codeine: Codeine is contraindicated in children after tonsillectomy due to risk of respiratory depression from ultra-rapid metabolism. Pain is mild, and bleeding—not pain—is the priority. Requesting codeine does not address the current danger of hemorrhage.

A. Orientation: The client is alert only to name and not fully oriented, indicating acute neurological changes. This requires immediate follow-up to assess for possible stroke or other neurological compromise.

B. Breath sounds: Breath sounds are vesicular and bronchovesicular with full thoracic excursion, which is within normal limits. No follow-up is immediately required.

C. Gag reflex: The absence of a gag reflex is a significant finding, increasing the risk of aspiration and airway compromise. Immediate assessment and interventions are necessary to protect the airway.

D. Pupils: Pupils are equal and reactive bilaterally, which is within normal limits. No follow-up is required for this finding.

E. Extremity circulation: Pulses are +2 with capillary refill less than 2 seconds in all extremities, indicating adequate perfusion. No follow-up is needed at this time.

F. Speech: The client’s speech is unintelligible, indicating acute neurological compromise. This requires urgent follow-up and possible intervention for stroke or transient ischemic attack.

G. Grip strength: Decreased grip strength in the right upper extremity indicates motor deficits consistent with neurological injury, requiring immediate assessment and intervention.

H. Thoracic findings: Full and symmetric thoracic excursion with normal breath sounds is within normal limits, requiring no follow-up.

I. Heart sounds: S1 and S2 are present, and the cardiac monitor shows sinus tachycardia without additional abnormalities, which does not require immediate follow-up.