After discharge from the postanesthesia care unit (PACU), the client r

After discharge from the postanesthesia care unit (PACU), the client returned to the surgical nursing unit at 10:00 AM. It is now 11:30 AM, and the client is not experiencing any complica-tions or difficulties.

The nurse will plan to measure the client’s vital signs:
1. Every 15 minutes
2. Every 30 minutes
3. Every 1 hour
4. Every 4 hours

ANSWER

ANS: 3
Vital sign monitoring on the postoperative nursing unit should initially be hourly for 4 hours and then every 4 hours. As the client’s condition stabilizes, the frequency of assessment will usually decrease to once a shift until discharge. Upon the client’s arrival to recovery, the nurse repeats measurement of vital signs every 15 minutes, not for the client who is stable on the surgical nurs-ing unit. The client who is not experiencing any complications or difficulties does not require vi-tal sign measurement every 30 minutes. After the client’s vital signs are obtained hourly for 4 hours and remain stable, the client may have his or her vital signs measured every 4 hours.