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Difficulty: MediumPhysiological Adaptation

Following a tonsillectomy, a young adult client is resting on the surgical unit. The practical nurse observes the sleeping client making repeated swallowing motions. The client's heart rate has climbed to 114 beats per minute from a baseline of 72 beats per minute. Which action should the practical nurse prioritize?

  1. A
    Provide the scheduled dose of intravenous analgesic to ensure comfort.
  2. Awaken the client and carefully inspect the throat using a penlight.Answer
  3. C
    Note the current vital signs in the chart and continue to observe quietly.
  4. D
    Instruct the client to cough forcefully to clear any accumulated secretions.

Answer

The correct approach is to awaken the client and carefully inspect the throat using a penlight.
Frequent swallowing combined with unexplained tachycardia after throat surgery strongly suggests active hemorrhage. Inspecting the surgical site directly with a penlight is the critical first step in data collection to confirm bleeding and escalate care.

Step-by-Step Solution

1
Identify the clinical significance of frequent swallowing after throat surgery.
Frequent swallowing is a primary indicator of active bleeding as blood drips down the posterior pharynx.
Recognizing early postoperative complications is essential for client safety.
2
Analyze the vital sign changes.
The transition from a baseline heart rate of 72 to 114 beats per minute is an early compensatory sign of potential hypovolemia.
Tachycardia often precedes hypotension in the early stages of hemorrhagic shock.
3
Prioritize the nursing response.
Direct visualization of the surgical site is necessary to confirm active hemorrhage before rapidly escalating the situation to the registered nurse or provider.
The practical nurse must collect focused data to inform immediate emergency interventions.

Key Concept

Postoperative Hemorrhage Recognition
Estimated Time:1m 0s
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Topics

Physiological Adaptation

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