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Difficulty: HardReduction of Risk Potential

A 21-year-old client is recovering on the surgical unit 5 hours after undergoing an adult tonsillectomy. A family member summons the practical nurse, stating that the client appears highly anxious and is swallowing continuously. The nurse obtains vital signs, noting a heart rate of 112 beats per minute, a respiratory rate of 20 breaths per minute, and a blood pressure of 104/66 mm Hg, compared to a preoperative baseline of 124/76 mm Hg. The client points to their neck and grimaces, indicating significant throat discomfort. Which action should the practical nurse implement first?

  1. Inspect the back of the throat using a penlight and immediately notify the supervising registered nurse.Answer
  2. B
    Administer the prescribed liquid oral analgesic to alleviate the client's severe throat pain.
  3. C
    Document the findings as expected postoperative recovery and reassess the client in one hour.
  4. D
    Increase the continuous intravenous fluid rate independently to stabilize the client's blood pressure.

Answer

The practical nurse should inspect the back of the throat using a penlight and immediately notify the supervising registered nurse.
The correct action involves gathering rapid, focused assessment data (looking for blood in the throat) and immediately reporting these critical findings. Continuous swallowing, restlessness, an increasing heart rate, and decreasing blood pressure are classic indicators of postoperative hemorrhage following a tonsillectomy. Escaping blood often drains down the back of the throat, causing the client to swallow repeatedly. Because this is a life-threatening complication that threatens both airway and circulation, the practical nurse must escalate the situation to the registered nurse or provider without delay.

Step-by-Step Solution

1
Analyze the clinical presentation and vital sign trends.
The client exhibits continuous swallowing, anxiety, tachycardia (112 bpm), and a decrease in baseline blood pressure.
These specific behavioral and physiological signs strongly suggest active bleeding in the postoperative tonsillectomy client.
2
Determine the priority framework for intervention.
Airway and Circulation (hemorrhage risk) take precedence over pain management.
Bleeding in the airway can lead to rapid compromise and hypovolemic shock, requiring immediate life-saving action.
3
Select the appropriate nursing action within the practical nurse's scope of practice.
The nurse gathers focused visual data (inspecting the throat) and immediately escalates the findings.
A practical nurse must safely collect relevant data and report critical changes to the registered nurse or healthcare provider to ensure timely medical intervention.

Key Concept

Recognizing early signs of hemorrhage and escalating care appropriately within the practical nursing scope of practice.
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Reduction of Risk Potential

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