The nurse is assessing a post-operative client and notices that the client's urine is brown and they are experiencing muscle rigidity. The vital signs are T: 102.5 F; HR: 112; RR: 20 and BP 124/84. What is the most appropriate nursing action?

Choice A reason:
Administering an antiemetic is an important intervention in the PACU, especially if the patient is experiencing nausea or has a history of postoperative nausea and vomiting (PONV). However, it is not the first priority. Antiemetics work by blocking the neurotransmitters that trigger the vomiting reflex. Medications such as ondansetron or promethazine may be used.

Choice B reason:
Applying sequential compression devices is a preventive measure against deep vein thrombosis (DVT), which is a risk due to immobility after surgery. These devices help improve venous return from the lower limbs by applying intermittent pressure. While important, this intervention follows after the assessment of vital signs.

Choice C reason:
Assessing vital signs is the first and foremost priority when a patient is transferred to the PACU. Vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, provide immediate information about the patient's hemodynamic status and can indicate the need for urgent interventions. Any evidence of respiratory or circulatory compromise requires immediate attention.

Choice D reason:
Hanging the Lactated Ringers solution is part of managing the patient's fluid status postoperatively. Lactated Ringers is an isotonic solution that helps to replace lost fluids and maintain electrolyte balance. While important for patient care, it is not the initial priority upon arrival in the PACU.

Choice A reason:
Cyanosis, or a bluish discoloration of the skin, particularly in the nail beds, is a sign of inadequate oxygenation and would not indicate successful intervention. The absence of cyanosis would be a positive outcome, reflecting improved oxygen saturation.

Choice B reason:
Lungs clear to auscultation would indicate that air is moving through all regions of the lungs without obstruction from fluid or mucus, which is a sign of recovery from pneumonia. This finding suggests that the interventions aimed at improving gas exchange, such as positioning, deep breathing exercises, and suctioning if needed, have been effective.

Choice C reason: The inability to speak in full sentences often indicates respiratory distress and would not be a sign of successful nursing intervention. An improvement would be the client's ability to speak in full sentences without difficulty, reflecting better lung function and gas exchange.

Choice D reason:
Pulse oximetry readings between 94-96% on room air are within normal limits and indicate adequate oxygen saturation and gas exchange. This is a clear sign that the client's respiratory status has improved, and the interventions for Impaired Gas Exchange have been successful.

Choice E reason:
Bronchovesicular breath sounds are normal breath sounds heard over the major bronchi and are typically moderate in pitch and intensity. However, they are not specifically indicative of successful intervention for Impaired Gas Exchange. The absence of abnormal sounds such as crackles or wheezes would be more relevant.