The nurse assesses a client who has just been brought to the postanesthesia care unit (PACU). In the operating room, the client's blood pressure was 136/80 mm Hg; it is now 110/80 mm Hg. Urine output was 40 mL/hr and is now 10 mL/hr
Which action by the nurse is best? a. Awaken the client and encourage oral fluids.
b. Increase the IV of 0.9 NS as ordered to 100 mL/hr.
c. Put the client in Trendelenburg position.
d. Assess the client's levels of consciousness and pain.
B
One of the most sensitive and earliest indicators of vascular volume loss is decreased urine out-put. The nurse is concerned about urinary output less than 30 mL/hr because this may indicate that the kidneys are not being perfused. The nurse should increase the IV rate. Oral fluids are not an option at this point because the client has not recovered from the anesthesia. Placing the client in Trendelenburg position is not warranted because this puts pressure on the heart and lungs, li-miting their effectiveness. Assessing consciousness and pain can wait until later.
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