The client following major surgery under general anesthesia arrives on the nursing unit 4 hours following surgery. The first set of vital signs are T 37.6; P 100; R 30; and BP 100/68. The nurse's first action should be to:
a. Notify the health care provider.
b. Assess the vital sign readings from the recovery room.
c. position the client for comfort and assess pain level.
d. prepare to increase the client's IV rate and administer blood products.
ANS: B
Feedback
A Incorrect: This is not a necessary nursing action
B Correct: Before becoming alarmed by the client's vital signs, the nurse should check what the client's vital sign pattern was in PACU.
C Incorrect: The vital signs need to be addressed.
D Incorrect: This is a premature move for the nurse until the vital signs are compared with the vital sign pattern from PACU.
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