A nurse is caring for a client who recently had surgery and observes a sudden decrease in the client’s BP along with an increase in HR. Which action should the nurse take first?
Check the client’s oxygen saturation.
Notify the healthcare provider promptly.
Increase the client’s IV fluid rate.
Assess the client for signs of bleeding.
The correct answer is to assess for signs of bleeding because a sudden drop in BP with tachycardia (increased HR) is often a compensatory response to hypovolemia caused by hemorrhage or significant fluid loss, which requires immediate evaluation and intervention. While increasing IV fluids might seem logical, initiating this without confirming bleeding can delay identifying the underlying issue and worsen the condition. Checking oxygen saturation does not directly address the hemodynamic instability, and notifying the healthcare provider promptly should occur after assessing and gathering critical information to relay.
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