One hour after admission to the PACU, the postoperative client has become very restless. What is the nurse's best first action?
A. Ask the client if he or she is having pain.
B. Check the client's oxygen saturation level.
C. Document the finding as the only action.
D. Explain to the client that he or she is in the "recovery room" after surgery.
B
The most common causes of restlessness in the immediate postoperative period are hypoxemia and pain. Although pain control is very important, determining the adequacy of ventilation in this case has higher priority.
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