Question

On admission of a patient to the postanesthesia care unit (PACU), the blood pressure (BP) is 122/72. Thirty minutes after admission, the BP falls to 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse is most appropriate?

a. Increase the IV fluid rate.
b. Continue to take vital signs every 15 minutes.
c. Administer oxygen therapy at 100% per mask.
d. Notify the anesthesia care provider (ACP) immediately.

Answer 1

The most appropriate action for the nurse is to continue to take vital signs every 15 minutes (option b) , as the patient's blood pressure is within the normal range and other signs do not suggest immediate distress.

Step-by-step explanation:

In response to the scenario where a patient's blood pressure drops slightly from 122/72 to 114/62 within 30 minutes of admission to the postanesthesia care unit (PACU), the appropriate nursing action would be option b. Continue to take vital signs every 15 minutes. The assessed vital signs indicate a slight decrease in blood pressure but are still within the normal range of mean arterial pressure (MAP), which falls within 70-110 mm Hg. The patient is also exhibiting a stable pulse of 74 and warm, dry skin, which does not suggest immediate distress. Moreover, a drop in blood pressure can be common after anesthesia and surgery. Monitoring the patient closely will allow for assessment of trends in blood pressure and other vital signs to ensure stability or to catch any signs of deterioration that would warrant further intervention.