The nurse is assessing a client admitted to the postanesthesia care unit (PACU) after abdominal surgery. The client's respiratory rate is 8 breaths/min and breath sounds are decreased in the bases. What is the nurse's priority action?
a. Prepare to administer naloxone (Narcan).
b. Assess oxygen saturation and level of consciousness.
c. Call a code or the Rapid Response Team.
d. Turn the client and perform chest physio-therapy.
B
Additional data are needed to determine respiratory status, so the nurse must finish the assess-ment with an oxygen saturation (SaO2) and check the client's level of consciousness. A respira-tory rate of less than 10 could indicate an emergency, especially if the SaO2 drops below 95%. A respiratory rate of less than 10 breaths/min may indicate anesthetic-induced depression. Naloxone should not be administered unless there are clear indications for it, and performing chest physiotherapy may not be warranted. Calling a code or the Rapid Response Team may be needed, but only after a complete assessment.
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