Upon observing a client who has returned post-tonsillectomy exhibiting restlessness and increased pulse rate, the nurse must:

Upon observing a client who has returned post-tonsillectomy exhibiting restlessness and increased pulse rate, the nurse must:

• A. Prepare the client for discharge.
• B. Notify the surgeon.
• C. Administer anti-nausea medication.
• D. Encourage deep breathing exercises.

Answer: (B)

The scenario presents a client who has recently undergone a tonsillectomy and is displaying signs of restlessness and an increased pulse rate. These symptoms can be indicative of potential complications following the surgery, such as bleeding or infection, which could lead to hemodynamic instability. Notifying the surgeon is crucial because these signs and symptoms warrant immediate evaluation to rule out any serious postoperative issues. Timely communication ensures that appropriate interventions can be started to mitigate any risks to the client’s health. The other options do not address the immediate concerns presented by the client’s symptoms. Preparing for discharge, for instance, would not be appropriate when a client exhibits signs of distress, as it may overlook possible complications needing medical attention. Administering anti-nausea medication would only address nausea if present but does not correlate directly with restlessness or increased pulse rate. Encouraging deep breathing exercises might help with relaxation, but given the context, it does not address the potential need for further evaluation by the surgeon. Therefore, notifying the surgeon is the most critical step in ensuring the client receives the necessary care.

The scenario presents a client who has recently undergone a tonsillectomy and is displaying signs of restlessness and an increased pulse rate. These symptoms can be indicative of potential complications following the surgery, such as bleeding or infection, which could lead to hemodynamic instability. Notifying the surgeon is crucial because these signs and symptoms warrant immediate evaluation to rule out any serious postoperative issues. Timely communication ensures that appropriate interventions can be started to mitigate any risks to the client’s health.

The other options do not address the immediate concerns presented by the client’s symptoms. Preparing for discharge, for instance, would not be appropriate when a client exhibits signs of distress, as it may overlook possible complications needing medical attention. Administering anti-nausea medication would only address nausea if present but does not correlate directly with restlessness or increased pulse rate. Encouraging deep breathing exercises might help with relaxation, but given the context, it does not address the potential need for further evaluation by the surgeon. Therefore, notifying the surgeon is the most critical step in ensuring the client receives the necessary care.