A nurse is caring for a 73-year-old client who underwent a laparoscopic cholecystectomy 24 hours ago. The client reports mild abdominal pain and dizziness when sitting up in bed. Their current heart rate is 118 beats per minute, respiratory rate is 24 breaths per minute, and blood pressure is 90/58 mmHg. What action should the nurse take first?
Notify the healthcare provider and await further instructions.
Lower the head of the bed and reassess the client’s vital signs.
Administer prescribed pain medication to address the client’s discomfort.
Offer oral fluids to the client to improve hydration.
The correct answer involves addressing the client's hemodynamic instability by lowering their head to improve blood flow to vital organs and preparing for further intervention. This action helps stabilize the client temporarily while the underlying cause is being assessed and treated. Administering pain medication is inappropriate because it doesn't address the client's unstable vital signs and could mask symptoms. Encouraging hydration by oral intake is unsafe when the client shows possible signs of shock or hypovolemia. Waiting for a provider could lead to critical delays in care.
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Physiological Integrity
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