A nurse is caring for a client in the ICU. The client's ECG monitor tracing reveals sinus bradycardia and S-T segment elevation. The client reports shortness of breath and feeling dizzy and faint. Which of the following medications should the nurse administer?

B. This is often the nurse's top priority in the PACU. Anesthesia can depress respiratory function, leading to hypoventilation or airway obstruction. The nurse assesses respiratory rate, effort, oxygen saturation, and auscultates breath sounds to ensure adequate ventilation. Addressing any respiratory compromise promptly is crucial to prevent hypoxia or respiratory arrest.

A Assessing the surgical site is important to monitor for bleeding, infection, or any other complications related to the procedure. However, immediately after surgery, other assessments take precedence over this unless there is a specific concern like excessive bleeding or signs of infection.

C. Monitoring the client's level of consciousness is vital to detect any signs of neurological complications or delayed emergence from anesthesia. The nurse assesses orientation, responsiveness, and neurological signs to ensure the client is awakening appropriately from anesthesia.

D. Assessing pain is important as clients may experience discomfort after surgery. Pain can also affect respiratory function and overall recovery. However, it is typically assessed after ensuring respiratory status and consciousness are stable, as uncontrolled pain can be managed once immediate physiological concerns are addressed.

A. Nuchal rigidity refers to stiffness or resistance to neck movement, especially when the client's head is flexed forward. It is a classic sign of meningitis due to irritation and inflammation of the meninges (the membranes surrounding the brain and spinal cord). This assessment helps to detect meningeal irritation, a hallmark of meningitis.

B. This action tests the deep tendon reflex, specifically the knee jerk reflex (patellar reflex). It assesses the integrity of the spinal cord and peripheral nerves. While it is part of a neurological assessment, it is not specifically related to the assessment of meningitis unless there are concurrent neurological symptoms or signs.

C This maneuver tests for Babinski reflex, which is an abnormal response where the toes flare upward and the big toe dorsiflexes when the sole of the foot is stimulated. A positive Babinski reflex can indicate dysfunction of the corticospinal tract or brain injury but is not a specific finding in meningitis.

D. Tapping the facial nerve (cranial nerve VII) assesses for the presence of facial nerve irritation or damage. In the context of meningitis, signs such as facial twitching or asymmetry may indicate involvement of cranial nerves due to inflammation and pressure within the skull.