A nurse is caring for a 9 year old child who underwent a tonsillectomy, which of the following observation by the nurse is most concerning?

Appeared in: RUHS, Jaipur, M.Sc Nursing Entrance Exam-2018

Explanation

Expectorating bright red secretions is a sign of active hemorrhage, which is the most serious and life-threatening complication after a tonsillectomy.
Fresh bleeding requires immediate medical intervention to control the source of bleeding and prevent complications like aspiration and hypovolemic shock.
Unlike other findings which are either normal or expected, active bleeding indicates a failure of hemostasis at the surgical site.

Option A: Vomiting or spitting up 30 ml of dark brown secretions represents old blood that was swallowed during the surgery. The stomach's acid turns the blood from red to brown.
Option B: A heart rate of 90 beats per minute is within the normal range for a 9-year-old child (typically 70-120 bpm).
Option C: Infrequent swallowing is an expected behavior after a tonsillectomy due to significant throat pain (odynophagia).

Clinical Relevance

Nursing practice connection: Use the key finding related to Post-operative complications following tonsillectomy in a pediatric patient to guide bedside assessment, documentation, and the next nursing action.
A nurse's primary responsibility after a tonsillectomy is vigilant monitoring for signs of hemorrhage, as it can occur without warning and progress rapidly.
Immediate action is critical. If active bleeding is suspected, the nurse should place the child in a side-lying position to prevent aspiration and notify the surgeon immediately. Emergency equipment should be readily available.
What if? If the child was 1-day post-op and developed a fever of 38.5°C (101.3°F) with foul-smelling breath, the most concerning issue would shift from hemorrhage to infection, requiring notification of the provider for possible antibiotic therapy.

How to Approach the Question

First, identify the core of the question: it asks for the 'most concerning' finding in a child post-tonsillectomy. This is a priority-setting question.
Second, analyze the patient and context: a 9-year-old child after a tonsillectomy. The key risk associated with this procedure is hemorrhage.
Third, evaluate each option based on the risk of immediate harm. Ask yourself, 'Which of these findings indicates a life-threatening complication?'
Option A (dark brown secretion) is old blood, expected.
Option B (HR 90) is a normal vital sign.
Option C (infrequent swallowing) is expected due to pain.

Concept Tested & Keywords

Concept Tested: Post-operative complications following tonsillectomy in a pediatric patient.
Stem keywords: 9 year old child, tonsillectomy, observation, most concerning
Lead-in keywords: most concerning
Clinical cues: The patient is a 9-year-old child, which influences normal vital sign ranges.
Clinical cues: The procedure is a tonsillectomy, which carries a significant risk of post-operative hemorrhage.

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E6 Nursing Brunner Adult Health 3SA Vol 2 Part 1 p. 37-39

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