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 A,B,C,D,E
Explanation
A. Trust vs. Mistrust: This stage occurs from birth to approximately 18 months of age. During this period, infants learn to trust their caregivers to meet their needs. If their needs are consistently met, they develop a sense of trust; otherwise, they may develop mistrust.
B. Autonomy vs. Shame and Doubt: From 18 months to 3 years, children begin to assert their independence. If caregivers encourage self-sufficient behavior, children become more autonomous; if they're overly criticized, they may develop feelings of shame and doubt.
C. Initiative vs. Guilt: Between the ages of 3 and 5, children start to initiate activities and assert control over their world through play and social interactions. Successful initiation leads to a sense of purpose, while failure results in feelings of guilt.
D. Industry vs. Inferiority: From 6 years to puberty, children compare themselves to their peers. They develop a sense of pride and accomplishment through their successes, or they may feel inferior if they do not measure up.
E. Identity vs. Role Confusion: During adolescence, teens explore different roles and ideas to form a personal identity. A well-established identity leads to the ability to stay true to oneself, while failure to establish an identity results in role confusion.
Correct Answer is B
Explanation
A. Encouraging deep breathing is important for preventing pulmonary complications but is not the priority in managing a vaso-occlusive crisis.
B. Maintaining hydration through intravenous fluids is the priority as it helps to reduce blood viscosity and prevent further sickling of cells, which is critical in managing a vaso-occlusive crisis.
C. Active range-of-motion exercises are important but are not a priority during an acute vaso-occlusive crisis.
D. A protein-rich diet supports overall health but is not immediately relevant to the acute management of a vaso-occlusive crisis.
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