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Difficulty: MediumReduction of Risk Potential

A licensed practical nurse is evaluating an adolescent client who arrived on the surgical unit three hours ago following a tonsillectomy. The client is observed to be swallowing continuously. The current vital signs reveal a heart rate of 118118 beats per minute and a blood pressure of 102/64102/64 mm Hg. Which action is the priority for the nurse to take?

  1. A
    Document the assessment as a normal expected finding for the early postoperative recovery period.
  2. B
    Administer a prescribed intravenous push antiemetic to prevent disruption of the surgical site from vomiting.
  3. Promptly notify the registered nurse about the continuous swallowing and the vital sign trends.Answer
  4. D
    Provide the prescribed oral liquid analgesic after confirming the client's first name and room number.

Answer

Promptly notify the registered nurse about the continuous swallowing and the vital sign trends.
Continuous swallowing after a tonsillectomy is a hallmark sign of active bleeding, as blood pools in the pharynx and stimulates the swallow reflex. The elevated heart rate of 118118 beats per minute is an early compensatory mechanism for hypovolemia. The practical nurse must prioritize client safety by immediately escalating these critical findings to the registered nurse for prompt surgical or medical intervention.

Step-by-Step Solution

1
Evaluate the clinical presentation of continuous swallowing and tachycardia.
Recognize these as classic signs of active postoperative bleeding.
Blood trickling down the back of the throat stimulates the swallow reflex, and the heart rate increases to compensate for ongoing fluid volume loss.
2
Identify the practical nurse's scope of practice in a potentially emergent situation.
Determine that an unstable client requires immediate registered nurse and provider intervention.
Practical nurses must escalate care for clients exhibiting signs of severe complications to ensure timely medical management and risk reduction.

Key Concept

Postoperative Hemorrhage Recognition and Escalation
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Topics

Reduction of Risk Potential

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