Randall Preston,a 49-Year-Old Healthy Male,is Beginning to Emerge from General

Randall Preston,a 49-year-old healthy male,is beginning to emerge from general endotracheal anesthesia after a transurethral laser lithotripsy of the left ureter.He is restlessly turning side to side and moaning.During the hand-off report from the anesthesia provider and circulating nurse,the perianesthesia nurse learned that Randall will probably continue to pass "sludge" (small granular ureteral stone material) for the next hour.As the surgical team rushes back to the OR to start the next case,the perianesthesia nurse thanks them and tells them they can go as she knows what is wrong with Randall and will take care of him.The perianesthesia nurse's comment reflects which phase of the nursing process and what will be her next actions?

A) The perianesthesia nurse's nursing diagnosis will prompt her to ask Randall to describe his pain.
B) She is in the implementation phase as she checks the patient record for analgesia orders.
C) She is in the assessment phase as she is not confident that Randall is awake enough to experience pain and continues to review vital signs and arouse him enough to speak.
D) She has established a nursing diagnosis and is going to press the button on his patient-controlled analgesia pump to get medication circulating before he is fully awake.