Difficulty: Medium
Average Score: 75%
Simulated
Passage / Scenario
A child in the immediate postoperative period after a tonsillectomy, spitting up small amounts of blood.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?
Correct answer
A
Rationale
The correct answer is A: Notify the healthcare immediately. Spitting up blood post-tonsillectomy could indicate hemorrhage, a potentially life-threatening complication. Immediate notification is crucial for prompt intervention. Continuing to assess for bleeding (B) may delay necessary medical attention. Suctioning (C) can worsen bleeding. Encouraging coughing (D) can exacerbate bleeding. Therefore, notifying healthcare immediately is the best intervention.