Medical Surgical Tonsillitis #1

Question

The nurse is caring for a client who is 12-hours postoperative tonsillectomy. Which assessment data will alert the nurse to a complication?

Answers

  1. Drainage from the throat on the client's pillow.
    • Rationale:

      This answer is not correct because drainage from the throat is to be expected after throat surgery. The client should be in the side-lying position or prone to facilitate drainage, which will cause respiratory fluids to drain out onto the pillow.

  2. The client is swallowing frequently.
    • Rationale:

      This answer is correct because frequent swallowing is a sign of hemorrhage from the throat due to the throat’s vascularity. If hemorrhage occurs, the client should turn the client to the side and notify the provider right away. Postsurgical hemorrhage after a tonsillectomy is a medical emergency.

  3. Persistent coughing by the client.
    • Rationale:

      This answer is not correct because persistent coughing by the client is most likely due to the throat drainage or the breathing tube that was placed during the surgery. Position the client in the side-lying position or prone, and discourage the client from coughing too much or clearing the throat, as this could cause hemorrhage.

  4. The client lying in the supine position.
    • Rationale:

      This answer is not correct because although lying in the prone or side position is preferred post tonsillectomy, lying in the supine position is not a complication. Lying in the supine position can cause drainage down the back of the throat and be potentially aspirated. But lying supine is not evidence of a complication.

Overview

The most common complication after a tonsillectomy is hemorrhage due to the throat’s vascularity. Evidence of a throat hemorrhage is a client swallowing frequently.

Explanation

Learning Outcomes

The most common complication after a tonsillectomy is hemorrhage due to the throat’s vascularity. Evidence of a throat hemorrhage is a client swallowing frequently. If hemorrhage occurs, the client should turn the client to the side and notify the provider right away. Postsurgical hemorrhage after a tonsillectomy is a medical emergency. Drainage from the throat is normal after a tonsillectomy. The side-lying or prone position facilitates drainage and helps prevent infection. Coughing and clearing the throat is discouraged due to the potential for hemorrhage.

Test Taking Tip

With surgeries, know the number one complication and what to monitor.

Video Rationale