The nurse assesses a patient who has just arrived in the postanesthesia recovery area (PACU) after a blepharoplasty. Which assessment data should be reported to the surgeon immediately?
a. The patient complains of incisional pain.
b. The patient's heart rate is 110 beats/minute.
c. The patient is unable to detect when the eyelids are touched.
d. The skin around the incision is pale and cold when palpated.
ANS: D
Pale, cool skin indicates a possible decrease in circulation, so the surgeon should be notified immediately. The other assessment data indicate a need for ongoing assessment or nursing action. A heart rate of 110 beats/minute may be related to the stress associated with surgery. Assessment of other vital signs and continued monitoring are appropriate. Because local anesthesia would be used for the procedure, numbness of the incisional area is expected immediately after surgery. The nurse should monitor for return of feeling.
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