Health Promotion and Maintenance
14. A nurse assesses a child who is 12 hours status post–tonsillectomy and adenoidectomy. The child reports feeling nauseated and shows the nurse a moderate amount of red-tinged vomitus in the emesis basin. Which action should the nurse take first?
. Administer an antiemetic as ordered.
. Offer the child ice chips as tolerated.
. Report the findings to the physician.
. Apply bilateral pressure to the child's neck.
Test-Taking Tip
When the stem of a question appears to indicate active bleeding in a client, it is likely to be a medical emergency. The proper initial response is to stop the bleeding if possible. In this case, the bleeding is in the airway so only the physician is capable of stopping the bleeding.
Content Area: Child Health, Respiratory; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Complications from Surgical Procedures and Health Alterations
Health Promotion and Maintenance
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Answer 1 is incorrect because administering an antiemetic fails to recognize the seriousness of the child's symptoms, thereby placing the child in danger. Answer 2 is incorrect because offering ice chips may induce further vomiting and is contraindicated in the client who is nauseated. Answer 3 is correct because the appearance of moderate red-tinged vomitus could indicate hemorrhage in the surgical area. The physician should be notified immediately of this potentially harmful complication. Answer 4 is incorrect because the application of pressure to the child's neck is contraindicated and would not resolve potential incisional bleeding and might block the carotid arteries, thereby causing harm to the child.