High School

The surgery is succesfully completed without complications. Following surgery, Ms. Jackson is admitted to the Post Anesthesia Care Unit. The operative report indicates that Ms. Jackson has a left hip replacement under general anesthesia. The initial nursing assessment reveals that Ms. Jackson is not responding to verbal stimuli. Her vital signs are T 97.6 F, P 88, RR 14, and BP 130/70. What action should the nurse implement first? A. Position the client on her side. B. Observe the surgical dressing. C. Place the call bell within reach. D. Remove the oral airway.

Answer :

Final answer:

The nurse should place the call bell within reach for Ms. Jackson, as she is not responding to verbal stimuli. This will allow her to alert the nurse if she needs assistance.

Explanation:

The nurse should first place the call bell within reach for Ms. Jackson, as she is not responding to verbal stimuli. This will allow her to alert the nurse if she needs assistance. While positioning the client on her side, observing the surgical dressing, and removing the oral airway are important nursing actions, ensuring that the client can call for help is the priority in this situation.

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