Difficulty: Medium
Average Score: 68%
Simulated
The client has returned to the surgery unit from the Post Anesthesia Care Unit (PACU). The client's respirations are rapid and shallow, the pulse is 120, and the blood pressure is 88/52. The client's level of consciousness is deteriorating. The nurse should do which of the following first?
Correct answer
D
Rationale
Rapid, shallow respirations, tachycardia, hypotension, and deteriorating consciousness suggest shock or respiratory distress. Calling the Rapid Response Team ensures immediate intervention.