Difficulty: Medium
Average Score: 75%
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 be a sign of pain anxiety hypoxia or other complications and should be addressed promptly. Blood pressure 110/70 and heart rate 86 are within normal ranges hypoactive bowel sounds are common post-operatively and a negative Homan's sign is a positive finding.