The nurse has just received a client from the surgical area. After 30 minutes in the recovery area, the client's vital signs are as follows: pulse 92; blood pressure 110/50; respirations 12; pulse oximeter 86%
What should be the initial nursing response? 1. Stimulate the client.
2. Call the physician.
3. Ask another nurse for his or her opinion.
4. Place an oral airway in the client.
Stimulate the client.
Rationale: The client's respirations and pulse oximeter are low. The initial response by the nurse should be to stimulate the client to see if the pulse oximeter will increase. The client may require frequent stimulation to improve the oxygen saturation. If the oxygen saturation does not stay up after stimulation, the nurse may wish to advise the physician. An oral airway may be necessary if the client is not easily aroused. It is not necessary to ask for a second opinion.
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