A patient recovering from surgery becomes restless, has a drop in blood pressure, increase in heart rate, and is breathing at a rate of 30 per minute. Which action should the nurse take first?
a. Monitor vital signs.
b. Maintain a patent airway.
c. Notify the patient's family.
d. Ensure physician is informed.
ANS: B
The patient is experiencing a complication and must be carefully monitored to ensure that a patent airway is maintained. A. Then vital signs can be obtained. C. The physician should be notified. D. If appropriate, the family can be notified of the change in patient's condition.
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