A patient who is recovering from surgery becomes restless and pale. The heart rate rises from 88 to 124 per minute, the respiratory rate rises to 28, and urine output falls. What is the nurse's priority action?
Correct answer: A. Perform an immediate focused assessment and escalate the deterioration
- A. Perform an immediate focused assessment and escalate the deterioration
- B. Reassure the patient that these changes are common after surgery
- C. Offer oral fluids and review the condition during the next round
- D. Give the prescribed analgesic before assessing the vital signs
Explanation
Restlessness, pallor, tachycardia, tachypnoea, and reduced urine output form a concerning pattern of possible shock or serious deterioration. The nurse should rapidly assess airway, breathing, circulation, vital signs, and the surgical site, then escalate according to local emergency procedures. Reassurance, fluids, or analgesia must not replace urgent assessment.
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About Clinical Judgement and Prioritisation
Clinical judgement links assessment findings, nursing knowledge and patient responses to a safe decision. Coverage includes ABCDE assessment, recognising actual or potential instability, prioritising airway, breathing and circulation, using urgency and risk rather than routine order, reassessing after intervention, and distinguishing a nursing priority from a medical diagnosis or a task that can wait.
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