A client who is being admitted to the postanesthesia care unit (PACU) has weak hand grasps on assessment and is unable to lift his head off the bed. During hand-off report, the nurse notes that the client has received a neuromuscular-blocking agent
What is the nurse's best action? a. Document the finding.
b. Check the client's pulses.
c. Place the client in Fowler's position.
d. Auscultate the lungs.
D
When neuromuscular blocking agents are used, the client is at risk that these agents could be re-tained. The primary concern is the client's airway owing to muscular weakness. Because the client cannot raise the head and has a weak hand grasp, this may be a potential problem. The nurse should document all assessment findings. Placing the client in Fowler's position and checking the pulses is not warranted.
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