Difficulty: Medium
Average Score: 93%
Simulated
The nurse is assessing the status of a post-operative client in the PACU. The nurse should be most concerned with which assessment finding?
Correct answer
D
Rationale
Increased restlessness can indicate pain, anxiety, or a worsening condition, such as hypoxia or bleeding, making it the most concerning finding requiring immediate attention. Hypoactive bowel sounds are common post-operatively, pain rated 7/10 is expected and manageable, and BP 110/70 with HR 86 are within normal limits.