The nurse is assessing a patient who has just arrived in the postanesthesia recovery area (PACU) after a blepharoplasty. Which of these assessment data will require the most immediate action by the nurse?

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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. Pain at the 5/10 level would be unusual, but pain is highly individual and subjective, so the nurse should treat the pain and continue to monitor the patient. A heart rate of 110 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.

The Nurse Is Assessing a Patient Who Has Just Arrived