A 6 year old had a tonsillectomy today. When the nurse goes into the room to give him his antibiotics, she finds him irritable, coughing, nauseated, and swallowing repeatedly. What is the next action the nurse should take?
1. Assess for signs of frank red blood in the mouth and nose and get a complete set of vital signs.
2. Ask the child for a pain score and if he would like a popsicle with his pain medicine.
3. Suction mouth vigorously to avoid aspiration of blood, and then hang antibiotic.
4. Take a complete set of vital signs and divert the child's attention to the cartoon on TV.
1
Feedback
1. This intervention assesses for bleeding.
2. An assessment for blood needs to occur because the child continues to swallow.
3. Suctioning can cause clots to loosen and increases bleeding. It should be avoided.
4. Vital signs are needed and a focused assessment needs to be completed in order to identify complications.
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