Question

The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, and respirations 30. Which action by the nurse should receive priority?

A. Continuing to monitor the vital signs
B. Contacting the physician
C. Asking the client how he feels
D. Asking the LPN to continue the post-op care

Answer 1

When a patient presents with post-operative vital signs indicative of shock, the nurse's priority is to contact the physician immediately. Blood pressure readings, elevated heart rate, and quick breathing suggest a critical condition that necessitates immediate medical intervention.

Step-by-step explanation:

The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, and respirations 30. The nurse's priority action should be contacting the physician immediately. These vital signs suggest the patient may be in a state of shock, possibly due to hemorrhage or other complications. A blood pressure of 90/50 indicates hypotension, a pulse rate of 132 is tachycardic (indicating a high heart rate), and 30 respirations per minute is tachypneic (indicating rapid breathing). These signs require prompt medical intervention to stabilize the patient. While monitoring the vital signs is important, it should not delay informing the physician of the patient's critical condition. Asking the client how they feel and delegating care to an LPN are secondary actions that do not address the immediacy of the situation.