A patient who had recent abdominal surgery is becoming increasingly agitated and confused. He has pulled out his IV and his nasogastric tube. His skin is pale and clammy, heart rate 120 bpm, BP 130/60. The physician has been called. What nursing action is most important at this time?
A) Gather needed supplies and assign the aide to remain with the patient.
B) Stay with the patient and have another nurse obtain needed supplies.
C) Administer pain medication and then recheck vital signs.
D) Assign the aide to retake vital signs every 15 minutes.

Question

Quizplus · Accepted Answer

Staying with the patient while another nurse obtains needed supplies is the best action because the patient's condition is deteriorating. Asking the aide to stay with the patient and assigning the aide to take vital signs every 15 minutes are inappropriate delegations. Administering pain medication is an incorrect action because the patient is not complaining of pain.

A Patient Who Had Recent Abdominal Surgery Is Becoming Increasingly