A child has just returned to the surgical floor after undergoing a tonsillectomy. Which of the following actions should the nurse take first?
• After a tonsillectomy, the patient is at high risk for hemorrhage in the first 12 to 24 hours postoperation.
• The nurse should inspect for signs of bleeding in the throat such as increased frequency of swallowing, blood in the oropharynx, and nausea from blood in the stomach.
• Cold or frozen treats are often given to soothe the throat and increase fluid intake, but anything with red coloring is avoided because it can mask signs of bleeding.
• Assessing orientation and LOC are not priority actions.
• Trendelenburg position would lower the head below the level of the feet and is contraindicated with risk of bleeding in the throat or head.