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.

Answer and Explanation

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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Correct Answer is D

Explanation

A. Contact precautions are used for infections that spread through direct or indirect contact with contaminated surfaces or items, which is not the case for measles.

B. Droplet precautions are used for infections spread through large respiratory droplets, such as influenza, but measles requires different precautions.

C. Protective environment precautions are used for immunocompromised patients to prevent infections but are not specific to measles.

D. Measles is spread through airborne droplets, so airborne precautions are required to prevent the spread of the virus through the air.

A. A cough that accompanies a cold should not be suppressed. B. An antibiotic is prescribed for children younger than 5 years of age. C. Typically, the child will pull the ear when a cold is present. D. Healthy children rarely have more than one cold per year.

Correct Answer is A

Explanation

A. Coughing helps to clear mucus from the airways, and suppressing it can lead to complications such as mucus buildup and infection.

B. Antibiotics are not prescribed for viral infections like the common cold unless there is a secondary bacterial infection.

C. Ear pulling may indicate ear discomfort or infection, but it is not a typical response to nasopharyngitis alone.

D. It is normal for young children to have multiple colds per year due to their developing immune systems.

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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?

Nursing Test Bank

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