Which of the post-operative instruction following tonsillectomy is incorrect?

RUHS, Jaipur, M.Sc Nursing Entrance Exam-2016

Medical & Surgical Nursing

Medium

Appeared in: RUHS, Jaipur, M.Sc Nursing Entrance Exam-2016

Explanation

Routine suctioning of the throat is contraindicated after a tonsillectomy as it can traumatize the delicate, healing surgical site.
The primary danger of suctioning is dislodging the protective clot that forms over the tonsillar bed, which can lead to severe hemorrhage.
Suctioning should only be performed with extreme caution and gentleness, and only if there is a clear indication of airway obstruction that cannot be resolved by other means.

Option A: This is a correct and essential nursing intervention. Monitoring for bleeding is the highest priority after a tonsillectomy.
Option C: This is a correct instruction. Once the patient is fully awake and the gag reflex has returned, offering clear, cool liquids is important for hydration and comfort.
Option D: This is a correct instruction. Milk and milk products can increase the thickness of mucus in the throat, prompting the patient to cough or clear their throat, which can disrupt the surgical site and cause bleeding.

Clinical Relevance

Nursing practice connection: This is primarily an exam-oriented knowledge point with limited direct bedside application, so retain Post-operative nursing care following tonsillectomy as background academic context rather than a clinical decision trigger.
A nurse's primary responsibility post-tonsillectomy is vigilant monitoring for hemorrhage, the most life-threatening complication.
Early detection of bleeding is critical. Frequent swallowing is often the earliest and most subtle sign that a patient, especially a child, is swallowing blood from the surgical site.
Patient and family education is vital. Instructions must be clear about avoiding activities that can cause bleeding, such as coughing, vigorous gargling, and eating rough foods.

How to Approach the Question

First, identify the core of the question: it asks for an INCORRECT action, which is a negative-lead-in question.
Your goal is to evaluate each of the four options and determine which one is NOT a standard or safe practice after a tonsillectomy.
Think about the primary risks after this specific surgery. The main risk is hemorrhage from the surgical site in the throat.
Evaluate each option based on this risk. Does the action prevent bleeding or cause it?
Option A (Monitor for bleeding) is a safety measure. Option C (Clear fluids) is for hydration. Option D (No milk) prevents throat clearing. These all seem like reasonable precautions.
Option B (Suction every 2 hourly) involves putting an instrument into the sensitive surgical area. This action carries a high risk of disrupting the clot and causing bleeding. Therefore, it is the incorrect and dangerous instruction.

Concept Tested & Keywords

Concept Tested: Post-operative nursing care following tonsillectomy
Stem keywords: post-operative instruction, tonsillectomy
Lead-in keywords: incorrect
Negative lead-in flag: The question asks for the INCORRECT statement, meaning three options are correct nursing actions and one is a contraindicated action.