The postoperative vital signs of an average size adult client are: BP

The postoperative vital signs of an average size adult client are: BP = 110/68 mm Hg, P = 54 beats/min, R = 8 breaths/min. The client appears pale, is disoriented, and has minimal urinary output. The nurse should:

1. Retake the vital signs in 30 minutes
2. Continue with care as planned
3. Administer a stimulant
4. Notify the physician

ANSWER

ANS: 4
The nurse should notify the physician, as these are abnormal findings. The client’s respirations are becoming dangerously low at 8 breaths/min (normal 12-20 breaths/min). The client’s pulse rate is low at 54 beats/min (expected 60-100 beats/min), and the blood pressure should be =120/80 mm Hg, which it is at 110/68 mm Hg. The additional assessment findings are also not normal, and should be reported to the physician. The nurse should not wait another 30 minutes to retake vital signs. The present readings warrant notifying the physician. These are abnormal findings. The nurse should not continue with care as planned. The nurse should first notify the physician. Ad-ministering a stimulant would require a physician’s order and may not be what the client requires. For example, the client may need a narcotic antagonist rather than a stimulant.