Difficulty: Medium
Average Score: 64%
Simulated
A client is transferred to the Postanesthesia Care Unit (PACU) after surgery. The priority nursing intervention is:
Correct answer
C
Rationale
The correct answer is C: Assessing vital signs. This is the priority nursing intervention because it allows the nurse to monitor the client's immediate postoperative condition for any signs of instability such as hypotension, tachycardia, or respiratory distress. Vital signs provide crucial information about the client's overall physiological status and help in early identification of any complications. Administering an antiemetic (A) may be necessary if the client is experiencing nausea or vomiting but does not take precedence over assessing vital signs. Applying sequential compression devices (B) is important for preventing deep vein thrombosis but is not the immediate priority upon arrival in the PACU. Hanging the Lactated Ringers solution (D) may be necessary but should come after assessing vital signs to ensure the client's stability.