A patient in the post-anaesthesia care unit has a blood pressure of 84/50 mmHg, a pulse of 118 per minute and cool, pale skin. What is the nurse's priority action?
Correct answer: B. Assess the airway and breathing immediately
- A. Offer clear fluids by mouth
- B. Assess the airway and breathing immediately
- C. Assist the patient to stand and walk
- D. Give the prescribed oral analgesic first
Explanation
Airway and breathing are assessed first because the ABC principle takes priority in an unstable postoperative patient. After immediate assessment, the nurse provides oxygen and seeks urgent help while evaluating possible bleeding or fluid loss.
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About Perioperative Nursing
Covers preoperative assessment, informed consent, surgical preparation, anaesthesia, intraoperative safety and postoperative recovery. It includes sterile technique, surgical positioning, wound and drain care, pain and nausea management, fluid balance, prevention of infection and recognition of complications such as haemorrhage, atelectasis and shock.
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