The nurse is caring for the client who has undergone a tonsillectomy. The nurse should monitor the client carefully for:
1. intake of food and fluids.
2. excessive bleeding.
3. increased urine output.
4. progression of the respiratory infection.
Answer: 2
1. The nurse will monitor intake of fluids, but it is not the priority of care.
2. Because the tonsils are very vascular, the client is at risk for hemorrhage following surgery. The nurse should monitor the client closely for excessive bleeding.
3. The nurse would not be concerned about increased urine output unless the client was diabetic.
4. The client with an infection is not eligible for surgery until the infection is healed.
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