After the insertion of an arteriovenous graft (AVG) in the right forearm, a patient complains of pain and coldness of the right fingers. Which action should the nurse take?

A. Notify the surgeon that the informed consent process is not complete.The nurse should inform the surgeon because the surgeon is responsible for ensuring that the patient has adequate information and understands the procedure. It is not appropriate for the nurse to proceed with the consent process if the patient has questions or uncertainties.

B. Notify the operating room nurse to give a more complete explanation of the procedure.While the operating room nurse plays a role in the surgical process, it is the surgeon’s responsibility to provide a complete explanation of the procedure.

C. Provide a thorough explanation of the planned surgical procedure.While it’s important to provide information, the nurse is not authorized to explain the surgical procedure in detail. The surgeon should explain the surgery, as they have the training and knowledge to address all aspects of the procedure and answer any specific questions.

D. Give the prescribed preoperative antibiotics and withhold sedative medications.Administering preoperative medications, including antibiotics, without completed informed consent would be inappropriate. The patient must fully understand the procedure and consent to it before any medications are given.

Anaphylaxis is a severe and potentially life-threatening allergic reaction that can lead to a rapid drop in blood pressure, known as hypotension. This drop in blood pressure is a critical indicator of the severity of the reaction and the effectiveness of the treatment provided. The nurse needs to monitor the patient's blood pressure closely to ensure it stabilizes and returns to a safe range.

While oxygen saturation, heart rate, and orientation are also important parameters to assess, they are secondary to blood pressure in evaluating the effectiveness of treatment for anaphylaxis. Oxygen saturation can help determine the adequacy of oxygenation, heart rate can indicate the presence of tachycardia (which may be a sign of an ongoing reaction or hypoperfusion), and orientation can provide information about the patient's mental status and potential complications.