A nurse is caring for a patient in the post-anesthesia care unit (PACU) who underwent a procedure two hours ago.

The nurse observes the following vital signs: heart rate 140 beats/minute, blood pressure 140/90 mm Hg, and respirations 26 breaths/minute.

Which intervention is most important for the nurse to implement?

Choice A rationale
Applying oxygen at 10 L via non-rebreather mask and monitoring pulse oximeter is the most important intervention for a patient in the post-anesthesia care unit (PACU) with a heart rate of 140 beats/minute, blood pressure 140/90 mm Hg, and respirations 26 breaths/minute.
These vital signs suggest that the patient may be experiencing hypoxia or respiratory distress, conditions that require immediate intervention.
Choice B rationale
Medicating for pain and monitoring vital signs according to protocol is important in the PACU, but it is not the most critical intervention in this scenario. The patient’s vital signs suggest a possible respiratory issue, which should be addressed immediately.
Choice C rationale
Encouraging the client to splint the incision with a pillow to cough and deep breathe is a common postoperative intervention to promote lung expansion and prevent atelectasis and pneumonia. However, in this scenario, the patient’s vital signs suggest a more immediate respiratory issue that requires prompt intervention.
Choice D rationale
Administering an intravenous fluid bolus as prescribed by the healthcare provider can be an appropriate intervention for certain conditions in the PACU, such as hypotension. However, in this scenario, the patient’s vital signs suggest a possible respiratory issue, which should be addressed immediately.

Choice A rationale
Obtaining a sputum sample is important for diagnosing respiratory infections, but it is not the priority intervention in this case. The patient’s symptoms of intermittent fever, night sweats, and a productive cough with small amounts of blood are indicative of a possible airborne disease such as tuberculosis.
Choice B rationale
Arranging transport for radiographic imaging can be helpful in diagnosing the patient’s condition, but it is not the immediate priority. The primary concern should be to prevent the potential spread of an airborne disease.
Choice C rationale
Moving the patient into airborne isolation is the priority intervention. This action is taken to prevent the spread of potential airborne diseases to other patients and healthcare workers.
Choice D rationale
Collecting specimens for blood cultures can help identify the causative organism if the patient has a systemic infection. However, given the patient’s symptoms and the potential for an airborne disease, moving the patient into isolation is the priority.