The postoperative vital signs of an average-sized adult client are BP, 110/68; P, 54; R, 8 . The client appears pale, disoriented, and has minimal urinary output. Which of the following actions should the nurse take?

Question

a. Retake the vital signs in 30 minutes.
b. Continue with care as planned.
c. Administer a stimulant.
d. Notify the physician.

Answer 1

D
The nurse should notify the physician, as these are abnormal findings. The client's respirations are becoming dangerously low at 8 (normal, 12 to 20 breaths per minute). The client's pulse is low at 54 (expected, 60 to 100 beats per minute), and the optimal blood pressure should be less than 120/80, while the client's blood pressure reading is 110/68 . The additional assessment findings also are not normal and should be reported to the physician.
The nurse should not wait another 30 minutes to retake vital signs. The present readings warrant notifying the physician.
These are abnormal findings. The nurse should not continue with care as planned.
The nurse should first notify the physician. Administering a stimulant would require a physician's order and may not be what the client requires. For example, the client may need a narcotic antagonist rather than a stimulant.