The nurse is assessing a client who has just arrived in the postanaesthesia recovery area (PACU) after a blepharoplasty. Which of the following assessment data is a priority?
A)The client complains of incisional pain.
B)The client's heart rate is 110 beats/minute.
C)The client is unable to detect when the eyelids are touched.
D)The skin around the incision is pale and cold when palpated.

Question

Quizplus · Accepted Answer

Pale, cool skin indicates a possible decrease in circulation, so the surgeon should be notified immediately. Warm, pink skin that blanches with pressure indicates that adequate circulation is present in the surgical area. The other assessment data indicate a need for ongoing assessment or nursing action. A heart rate of 110 may be related to the stress associated with surgery; assessment of other vital signs and continued monitoring are appropriate. Because local anaesthesia would be used for the procedure, numbness of the incisional area is expected immediately after surgery. The nurse should monitor for return of feeling.

The Nurse Is Assessing a Client Who Has Just Arrived