A nurse is assessing a client who is post-op tonsillectomy. Which of the following assessments would be a priority for the RN to intervene?

Rationale: A. Fever, decreased urine output, and refusal of oral liquids are concerning findings that may indicate dehydration or infection. Fever is a common post-operative response and usually peaks 1–3 days after surgery. Decreased urine output suggests the child may not be adequately hydrated, and refusal to take oral fluids can exacerbate this. While these findings warrant prompt attention and intervention, they are not immediately life-threatening in the immediate post-tonsillectomy period. Nursing interventions may include encouraging oral fluids, monitoring hydration status, and notifying the provider if the child’s output continues to decrease or fever persists. B. Postoperative pain is expected after a tonsillectomy and can usually be managed with prescribed analgesics. While pain management is important to maintain comfort and prevent complications such as poor oral intake, pain alone is not considered a priority over signs of acute complications like hemorrhage. The nurse should assess pain, administer analgesics as prescribed, and monitor the child’s response, but this is not immediately life-threatening. C. Enlarged cervical lymph nodes may indicate infection or inflammation, which is a common finding after tonsillectomy due to local tissue trauma or preexisting infection. While this may require monitoring and follow-up, it does not pose an immediate risk to airway or circulation, and therefore is not the highest priority in the acute postoperative period. D. Frequent swallowing is a key early indicator of postoperative hemorrhage, which is the most serious and potentially life-threatening complication after a tonsillectomy. Children may swallow blood without visible vomiting, making frequent swallowing a subtle but critical sign. Hemorrhage can lead to rapid blood loss, airway compromise, hypovolemic shock, and even death if not addressed immediately. The nurse’s priority is to assess the throat, monitor vital signs for signs of shock (e.g., tachycardia, pallor, hypotension), notify the surgeon immediately, and prepare for possible interventions such as suctioning, IV fluid resuscitation, or emergency surgery.