The client is one hour post aortic aneurysm repair. Over the previous one hour, the client's pulse rate has steadily increased from 80 to 110, with a gradual drop in blood pressure from 120/80 to 100/70. The nurse's best action is to:
a. notify the anesthesiologist, because the client may be reacting to the anesthesia.
b. continue to monitor the vital signs; it is normal to experience this after surgery.
c. ask the client if the pain level can be rated on a scale of 1-10.
d. continue to monitor the vital signs, because the change is probably related to the client experiencing pain.
ANS: C
Feedback
A Incorrect: There is not enough information in the scenario for this response.
B Incorrect: These changes are not considered normal in that there is a cause.
C Correct: Tachycardia and hypotension are physiologic responses to pain, so the client's pain level should be assessed and the client medicated as appropriate.
D Incorrect: The client should be medicated, if the pain rating scale indicates the need.
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