The nurse is collaborating with the dietitian about a client with a stage 3 pressure ulcer. After the collaboration the nurse orders a meal plan that includes increased

A. Orient the client to the room: Orientation is important for patient comfort and safety, especially after anesthesia when confusion may be present. However, it is not the priority action immediately upon arrival, as physiological stability must be assessed first before addressing environmental familiarity.

B. Assure the call light is within reach: Ensuring the call light is accessible supports patient safety and autonomy, particularly in preventing falls or unmet needs. Despite its importance, this intervention follows confirmation of the patient’s immediate physiological status.

C. Call the provider for orders: Orders are typically already established prior to transfer from the PACU. Contacting the provider without first assessing the patient may delay identification of urgent postoperative complications such as airway compromise, hemorrhage, or hemodynamic instability.

D. Assess vital signs: The immediate priority is to evaluate airway, breathing, circulation, and overall stability following anesthesia. Postoperative clients are at risk for complications such as respiratory depression, hypotension, and bleeding. Assessing vital signs allows early detection of deterioration and guides urgent interventions if needed.

A. Acute pain: Severe pain directly impacts the client’s ability to participate in rehabilitation, ambulate safely, and perform activities of daily living. Uncontrolled pain can also lead to physiologic stress responses, such as increased heart rate, blood pressure, and respiratory rate, which can compromise recovery. Addressing acute pain is the priority because it influences both safety and overall healing outcomes.

B. Risk for infection: While post-surgical infection is an important concern, it is a potential problem rather than an immediate issue. Infection risk requires monitoring and preventive measures but does not pose the same immediate threat to safety and functional ability as severe, uncontrolled pain.

C. Surgical repair: This is a medical intervention rather than a nursing diagnosis. While important, it does not reflect the client’s current priority need from a nursing perspective, which focuses on physiological and functional safety.

D. Impaired mobility: Impaired mobility is relevant in this post-op patient; however, mobility is currently limited by severe pain. Addressing pain first facilitates safe participation in mobility activities and rehabilitation, making it the more urgent concern.