Safe and Effective Care Environment Nclex PN Questions Related

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The LPN is caring for a 32-year-old female client who is 8 hours post-op after a tonsillectomy. Which of these actions would be appropriate for the nurse to take?

  • A. Inform the client that ear pain may occur and is normal.
  • B. Provide ice water and a straw to promote easy fluid consumption.
  • C. Provide hot tea to soothe the throat.
  • D. Monitor vitals every 15 minutes.
Correct Answer: A

Rationale: The appropriate action for the nurse to take is to inform the client that ear pain may occur and is normal after a tonsillectomy. Referred pain in the ear is common due to related nerve pathways. It is essential to educate the client about this to alleviate concerns. Providing ice water and a straw is not recommended as they may irritate the throat and disturb the healing process. Hot beverages like tea should also be avoided for the same reason. While monitoring vitals every 15 minutes is crucial in the immediate postoperative period for early identification of any complications, it is not the most appropriate action in this scenario where addressing the client's concerns and providing education is key.