The nurse is caring for a 20-year-old patient who recently underwent a tonsillectomy. The patient is fully awake and clearing his throat frequently but denies pain. Which action is most important for the nurse to take first?
a. Place the patient in a side-lying position.
b. Look in the patient's mouth.
c. Offer the patient a grape popsicle.
d. Remove the straw from the patient's tray.
B
Frequent swallowing or clearing of the throat may indicate bleeding. Further assessment is indi-cated, and the nurse should look in the patient's mouth to assess for bleeding.
The fully alert adult patient should be placed in semi-Fowler position to ensure adequate ventila-tion. Offering the patient a grape popsicle is an appropriate intervention once the nurse confirms that the patient is not bleeding. While removing the straw from the tray is an appropriate inter-vention to prevent bleeding that may result from sucking, the nurse should first ensure that the patient is not currently bleeding.
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