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    RN Comprehensive predictor 2023 proctored exam

    A nurse is caring for a 9-year-old child on the pediatric unit. Complete the following sentence by using the lists of options. The nurse should plan to _____ followed by _____ .

    Explanation & Rationale

    Rationale for correct choices • Inspect the child’s oropharynx: The child has bright red emesis and visible bleeding in the posterior pharynx, which indicates active post-tonsillectomy hemorrhage. Direct visualization helps confirm the bleeding source and severity. Early inspection supports rapid intervention because post-operative tonsillar bleeding can progress quickly and become life-threatening. • Obtaining a set of vital signs: Active bleeding and vomiting bright red blood require immediate reassessment of vital signs to detect tachycardia, hypotension, or respiratory compromise. Hemoglobin and hematocrit are already low, increasing the child’s risk for hemodynamic instability. Timely vital signs guide urgent decisions about fluid resuscitation and notifying the provider. Rationale for incorrect choices • Offer the child a red popsicle: Providing red-colored fluids can mask ongoing bleeding and delay recognition of hemorrhage. The priority is to assess and stabilize the child with known bleeding, not to offer oral intake. This intervention risks obscuring the color of emesis or oral bleeding. • Place the child in a supine position: Supine positioning increases the risk of aspiration when bleeding or vomiting is present. The child should be maintained upright to allow drainage and airway protection. Supine positioning does not address the current complication and may worsen respiratory safety. • Encouraging the child to cough and deep breathe: Coughing can dislodge clots and worsen post-tonsillectomy bleeding. The child already has active bright red bleeding, so stimulating airway pressure would increase hemorrhage risk. This intervention is inappropriate in immediate postoperative bleeding scenarios. • Requesting a prescription for codeine: Codeine is contraindicated in children after tonsillectomy due to risk of respiratory depression from ultra-rapid metabolism. Pain is mild, and bleeding—not pain—is the priority. Requesting codeine does not address the current danger of hemorrhage.

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