The nurse is caring for a client who has begun to awaken after 30 minutes in the postanaesthesia care unit (PACU), who is restless and shouting at the nurse. The client's oxygen saturation is 99%, and recent laboratory results are all normal. Which of the following actions by the nurse is most appropriate?

Question

Quizplus · Accepted Answer

Because the client's assessment indicates physiological stability, the most likely cause of the client's agitation is emergence delirium, which will resolve as the client wakes up more fully. The nurse should ensure client safety through interventions such as raising the bed rails and securing IV lines. Emergence delirium is common in clients recovering from anaesthesia, so there is no need to notify the anaesthesiologist. Insertion of an airway is not needed because the oxygen saturation is good. Orientation of the client is needed but is not likely to be effective until the effects of anaesthesia have resolved more completely.

The Nurse Is Caring for a Client Who Has Begun