The PACU nurse notes that a client is beginning to become increasingly restless. Nursing assessment includes blood pressure measurements dropping from to mm Hg, with heart rate increased to 120 beats/min, and dressings dry and intact
Which action by the nurse takes priori-ty? a. Increase rate of intravenous (IV) fluids.
b. Increase rate of oxygen (O2) delivery.
c. Notify the surgeon.
d. Place the client in the Trendelenburg position.
B
When a client appears to be going into shock, the PACU nurse applies O2 or increases the rate of O2 delivery, and then raises the client's legs above heart level, increases IV flow rate (unless contraindicated), and notifies the surgeon or anesthesiologist.
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