MED SURG 2 HESI TEST BANK REAL EXAM 100+ QUESTIONS AND CORRECT ANSWERS WITH RATIONALES|AGRADE

MED SURG 2 HESI TEST BANK REAL EXAM 100+ QUESTIONS AND CORRECT ANSWERS WITH RATIONALES|AGRADE • A client who just returned from the recovery room after a tonsillectomy and adenoidectomy is restless and her pulse rate is increased. As the nurse continues the assessment, the client begins to vomit a copious amount of brightred blood. The immediate nursing action is to: Notify the surgeon Continue the assessment Check the client’s blood pressure Obtain a flashlight, gauze, and a curved hemostat Rationale: Hemorrhage is a potential complication after tonsillectomy and adenoidectomy. If the client vomits a large amount of bright-red blood or the pulse rate increases and the patient is restless, the nurse must notify the surgeon immediately. The nurse should obtain a light, mirror, gauze, curved hemostat, and waste basin to facilitate examination of the surgical site. The nurse should also gather additional assessment data, but the surgeon must be contacted immediately. Test-Taking Strategy: Focus on the data in the question. Noting the words “brightred blood” will assist in directing you to the correct option. Remember that the lOMoAR cPSD| lOMoAR cPSD| presence of bright-red blood indicates active bleeding. Review the nursing actions to be taken immediately when bleeding occurs after a tonsillectomy and adenoidectomy if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., p. 657).