The PACU Nurse Notes That a Client Is Beginning to Become

question 21

Multiple Choice

The PACU nurse notes that a client is beginning to become increasingly restless. Nursing assessment includes blood pressure measurements dropping from (120/82) g to (90/60) mm Hg, with heart rate increased to 120 beats/min, and dressings dry and intact. Which action by the nurse takes priority?

• 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.

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