The nurse is caring for a child who has had a tonsillectomy. Which of the following are appropriate nursing interventions? Select all that apply.

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A tonsillectomy may be indicated in some cases of chronic tonsillitis, peritonsillar abscess, or obstructive sleep apnea. Postoperative bleeding is a primary concern after a tonsillectomy because the surgical site is not easily visualized and is vulnerable to irritation and trauma from swallowing and coughing. The nurse should observe for signs of postoperative bleeding (eg, frequent, increased swallowing or clearing of the throat; vomiting bright red blood) and notify the health care provider (Option D). Expected postoperative findings include ear pain when swallowing (ie, referred pain from the throat) and low-grade fever (<101 F [38.3 C]); analgesics (eg, acetaminophen) may be administered as needed (Option A). Superficial infection at the surgical site is common and causes white, fluid-filled exudate in the throat with halitosis (ie, bad breath); this is not concerning because it usually resolves spontaneously after 5-10 days (Option B). (Option C) Drinking through a straw creates suction that causes localized pressure at the back of the throat and may contribute to bleeding. The client should avoid use of straws or other pointed objects in the mouth. (Option E) Routine suctioning can cause trauma to the surgical site and induce bleeding. Suction equipment should be available but used only for emergency airway obstruction. Educational objective: Postoperative tonsillectomy interventions include close observation for signs of bleeding (eg, frequent swallowing) as well as avoidance of routine oral suctioning and the use of straws. Expected findings include white, fluid-filled exudate in the throat with halitosis, low-grade fever, and referred ear pain.

The Nurse Is Caring for a Child Who Has Had