A nurse is performing an assessment on a client receiving intravenous (IV) normal saline. The client reports discomfort and swelling at the (IV) site. The nurse needs to take appropriate actions to address the issue and prevent complications.

What condition might the nurse suspect based on the client's symptoms?

Choice A reason: Asking the UAP to reassess delays accurate assessment by a qualified nurse. Pulse 122 and BP 98/72 suggest tachycardia and hypotension, requiring professional validation and intervention, making this less appropriate than direct nurse reassessment and provider notification.

Choice B reason: Reassessing the client validates vital signs (pulse 122, BP 98/72), indicating tachycardia and hypotension, possibly from hypovolemia or sepsis. Accurate nurse assessment ensures reliable data for diagnosis, preventing complications like shock, making this a critical action in this scenario.

Choice C reason: Notifying the provider is essential, as tachycardia (pulse 122) and hypotension (BP 98/72) suggest serious conditions like hypovolemia or sepsis. Prompt reporting ensures timely interventions, such as fluids or diagnostics, preventing deterioration, making this necessary alongside reassessment.

Choice D reason: Sitting the client up may improve breathing but does not address tachycardia and hypotension, which suggest hypovolemia or other issues. These vital signs require reassessment and provider notification to diagnose and treat the cause, making positioning less urgent.

Choice A reason: Administering pain medication is important for comfort but not the most critical action upon PACU transfer. Pain is typically managed in the PACU, and respiratory complications like atelectasis or hypoxia are life-threatening, making respiratory assessment the priority to ensure client stability.

Choice B reason: Assessing respiratory status is critical upon PACU transfer, as postoperative clients risk respiratory complications like atelectasis or airway obstruction from anesthesia. Ensuring adequate oxygenation and ventilation prevents hypoxia, making this the priority to ensure client safety and detect early signs of respiratory distress.

Choice C reason: Checking the surgical dressing assesses for bleeding or infection but is secondary to respiratory status. Wound complications are less immediately life-threatening than respiratory issues, which can cause rapid hypoxia, making dressing checks a lower priority upon transfer to the medical-surgical unit.

Choice D reason: Monitoring urine output assesses renal function and fluid status but is not the most urgent upon PACU transfer. Respiratory complications pose a greater immediate risk, as anesthesia and surgery impair lung function, making respiratory assessment the priority to prevent hypoxia-related complications.