A client is recovering from a hysteroscopic myomectomy. The nurse assesses the client and finds the following: 2+ bilateral pedal edema; pulse, 108 beats/min; and respiratory rate, 28 breaths/min. Which action by the nurse takes priority?
a. Assess lung sounds and oxygen saturation.
b. Call for an immediate electrocardiogram (ECG).
c. Notify the health care provider as soon as possible.
d. Review the client's intake and output pat-tern.
A
This client has signs of fluid overload, which is a possible complication of hysteroscopic surgery. The nurse should assess the client's oxygenation status, then should notify the provider or call the Rapid Response Team. An ECG may be ordered but is not the priority, nor is reviewing intake and output patterns. Although the provider does need to be notified, the nurse needs further assessment data to report.
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