Question

the nurse notices that the patient who had surgery earlier in the day is now pale and restless with low blood pressure, tachycardia, and tachypnea. what is the nurse's priority action based on these findings?

Answer 1

The nurse should immediately assess the patient's airway, breathing, and circulation, increase IV fluids if necessary, alert the medical team for intervention, and continuously monitor vital signs to address potential signs of circulatory shock, which is a serious medical emergency.

Step-by-step explanation:

The nurse's priority action based on the findings that the patient is pale and restless with low blood pressure, tachycardia, and tachypnea is to assess the patient for signs of circulatory shock. These symptoms suggest that the patient may be experiencing a severe condition where the circulatory system fails to provide adequate blood flow, oxygen, and nutrients to the body's tissues.

Immediate actions should include:

1. Assessing the patient's airway, breathing, and circulation (ABCs).
2. Increasing the patient's intravenous fluids if hypovolemic shock is suspected.
3. Alerting the surgical or rapid response team to the patient's condition for potential interventions such as administration of vasopressors or transfusion.
4. Continuously monitoring the patient’s vital signs and urine output

The clinical signs point towards a decline in the patient's condition due to the surgery earlier in the day. To ensure patient safety and eventual recovery, all emergency actions must be implemented in a timely and efficient manner.