The nurse is caring for a female patient following a tonsillectomy and adenoidectomy. Two hours following the procedure, the patient begins to vomit large amounts of dark blood in frequent intervals and is tachycardic and febrile. After notifying the surgeon, the nurse will do which of the following?
a) Stay with the patient and monitor her closely.
b) Obtain a light, mirror, gauze, curved hemostats.
c) Prepare for a needle aspiration.
d) Orally suction the patient, as needed.
Answer: b) Obtain a light, mirror, gauze, curved hemostats.
Explanation:
If the patient vomits large amounts of dark blood at frequent intervals, or if the pulse rate and temperature rise, or the patient becomes restless, the nurse notifies the surgeon immediately. The nurse should have the following items ready for examination of the surgical site for bleeding: a light, a mirror, gauze, curved hemostats, and a waste basin. It is not necessary for the nurse to stay at the patient's bedside. Needle aspiration is a procedure considered for patients experiencing a peritonsillar abscess. Although oral suctioning may be needed at some point of care, it is not a priority at this time. pg.549
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