The postoperative vital signs of an average-sized adult patient are blood pressure 110/68 mm Hg, pulse 54 beats per minute, respirations 8 breaths per minute. The patient appears pale, seems disoriented, and has minimal urinary output
Which of the following actions should the nurse take? a. Retake the vital signs in 30 minutes.
b. Continue with care as planned.
c. Administer a stimulant.
d. Notify the physician.
D
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A The nurse should not wait another 30 minutes to retake vital signs. The present readings warrant notifying the physician.
B These are abnormal findings. The nurse should not continue with care as planned.
C The nurse should first notify the physician. Administering a stimulant would require a physician's order and may not be what the patient requires. For example, the patient may need a narcotic antagonist rather than a stimulant.
D The nurse should notify the physician, as these are abnormal findings. The patient's respirations are becoming dangerously low at 8 breaths per minute (normal range 12 to 20 breaths per minute). The patient's pulse is low at 54 beats per minute (expected range 60 to 100 beats per minute), and the optimal blood pressure should not be lower than 120/80 mm Hg, but the patient's blood pressure reading is 110/68 mm Hg. The additional assessment findings are also not normal and should be reported to the physician.
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