A patient's blood pressure in the postanesthesia care unit (PACU) has dropped from an admission blood pressure of 140/86 to 102/60 with a pulse change of 70 to 96. SpO2 is 92% on 3 L of oxygen
In which order should the nurse take these actions? (Put a comma and a space between each answer choice [A, B, C, D].)
a. Increase the IV infusion rate.
b. Assess the patient's dressing.
c. Increase the oxygen flow rate.
d. Check the patient's temperature.
ANS:
A, C, B, D
The first nursing action should be to increase the IV infusion rate. Because the most common cause of hypotension is volume loss, the IV rate should be increased. The next action should be to increase the oxygen flow rate to maximize oxygenation of hypoperfused organs. Because hemorrhage is a common cause of postoperative volume loss, the nurse should check the dressing. Finally, the patient's temperature should be assessed to determine the effects of vasodilation caused by rewarming.
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