The nursing assistant is caring for a client after surgery in an acute rehabilitation unit who suddenly develops pallor and drowsiness, and vital signs are as follows: BP 88/50, HR 110, RR 6. What action should the nursing assistant take first?

Question

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The nursing assistant (NA) takes the vital signs and observes that the client is unstable after surgery (decreased vital signs, a change in level of consciousness and drowsiness, and pallor of the skin). The first action should be to activate the emergency response system to get more trained help from the health care team right away. Next, the NA can ask the client to take some deep breaths and can try to keep the client responsive. The respirations are low, so the client may have received pain medication resulting in a decreased rate of respirations. The NA should be prepared to perform CPR if needed at any time. The NA should regularly observe the surgical dressing site to see if there is blood on the dressing or pooling of blood underneath the dressing site.

The Nursing Assistant Is Caring for a Client After Surgery