A nurse is assisting in the care of a client following a tonsillectomy who is alert and has an SpO2 of 93% on room air. Which of the following actions should the nurse take?
Explanation & Rationale
A. Encourage the client to use a straw to sip cool liquids: Using a straw can increase the risk of trauma to the surgical site, potentially causing bleeding. After a tonsillectomy, clients should sip liquids directly from a cup to protect the tonsillar area. B. Place the client in a semi-Fowler's position: Semi-Fowler’s position promotes optimal lung expansion, improves oxygenation, and helps prevent airway obstruction. This position supports respiratory function and is appropriate for a client with an SpO2 of 93%. C. Encourage the client to cough: Coughing can strain the surgical site and increase the risk of postoperative bleeding. Gentle deep breathing is preferred, while forceful coughing should be avoided until healing progresses. D. Obtain the client's peak expiratory flow volume: Peak expiratory flow measurement is not routinely indicated after a tonsillectomy. Focus should be on monitoring oxygenation, airway patency, and signs of respiratory distress rather than lung function testing.