In checking the neurologic status of the client just admitted to the PACU, the nurse notes that the right eye pupil is dilated more than the left pupil. What is the nurse's best first action?
A. Check the client's chart to compare these findings to the client's baseline neuro-logic assessment.
B. Raise the head of the bed up to a 30-degree angle and administer oxygen.
C. Test the client's deep tendon reflexes on all four extremities.
D. Notify the physician and document the finding.
A
Any abnormal neurologic assessment finding discovered postoperatively should be compared to the client's preoperative neurologic status. Unequal pupil size is a relatively common assessment finding in otherwise healthy adults.
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