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Difficulty: MediumPhysiological Adaptation

While observing an adolescent client on the surgical unit who had a tonsillectomy earlier in the day, the practical nurse notes that the client is restless and swallowing repeatedly. The continuous monitor shows a current heart rate of 118118 beats per minute, compared to a baseline of 8282 beats per minute. Which action should the practical nurse take FIRST?

  1. Examine the back of the client's throat using a penlight to check for active bleeding.Answer
  2. B
    Administer the prescribed as-needed liquid analgesic for postoperative throat pain.
  3. C
    Continue to monitor the client and plan to recheck the vital signs in one hour.
  4. D
    Assist the client into a flat, supine position to encourage sleep and reduce restlessness.

Answer

The priority action is to directly assess the surgical site for active bleeding.
Frequent swallowing, clearing of the throat, restlessness, and unexplained tachycardia (a heart rate of 118118 beats per minute) in a post-tonsillectomy client are classic early signs of hemorrhage. Because blood dripping down the back of the throat triggers the swallowing reflex, the priority action for the practical nurse is to directly assess the surgical site using a penlight. This immediate data collection is essential for determining the next steps to protect the airway and circulation before notifying the registered nurse.

Step-by-Step Solution

1
Analyze the clinical cues presented by the client.
The client exhibits restlessness, repeated swallowing, and tachycardia (heart rate of 118118 beats per minute).
Identifying abnormal findings is the first step in clinical judgment.
2
Correlate the symptoms with potential postoperative complications.
These specific signs strongly indicate postoperative hemorrhage, which is a medical emergency that compromises the airway.
Connecting symptoms to the surgical context (tonsillectomy) reveals the highest risk to the client's safety.
3
Determine the highest priority action based on the Airway, Breathing, Circulation (ABC) framework.
The nurse must visually inspect the throat to confirm bleeding before escalating to the registered nurse or provider.
Direct assessment provides the necessary clinical data to initiate emergency protocols and protect the client's airway.

Key Concept

Early recognition of hemorrhage and airway protection in postoperative tonsillectomy clients.
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Topics

Physiological Adaptation

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