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.

Question

Quizplus · Accepted Answer

When a client appears to be going into shock, the PACU nurse applies O₂ or increases the rate of O₂ delivery, and then raises the client's legs above heart level, increases IV flow rate (unless contraindicated), and notifies the surgeon or anesthesiologist.

The PACU Nurse Notes That a Client Is Beginning to Become