Question

A patient's blood pressure in the postanesthesia care unit (PACU) has dropped from an admission blood pressure of 140/86 to 102/60 with a pulse change of 70 to 96. SpO2 is 92% on 3 L of oxygen. In which order should the nurse take these actions? (Put a comma and a space between each answer choice [A, B, C, D].)

a. Increase the IV infusion rate.
b. Assess the patient's dressing.
c. Increase the oxygen flow rate.
d. Check the patient's temperature

Answer 1

The nurse should prioritize increasing the oxygen flow rate to address hypoxemia, followed by increasing the IV infusion rate to support blood pressure, then assess the patient's dressing for bleeding, and finally check the patient's temperature.

Step-by-step explanation:

When a patient's blood pressure drops significantly post-operatively and the pulse rate increases, the nurse needs to prioritize interventions to stabilize the patient. First and foremost, it is essential to increase the oxygen flow rate given the patient's SpO2 of 92% on 3 L of oxygen, as this will help address immediate concerns of hypoxemia. The nurse should then increase the IV infusion rate to support blood pressure. Assessing the patient's dressing comes next to check for possible bleeding, and then the nurse should check the patient's temperature last, as it is not as immediately life-threatening as the other concerns.

Therefore, the correct order of actions the nurse should take is:
C, A, B, D.