In the PACU, which assessment finding requires immediate nursing action?

The finding that the patient is restless, agitated, and hypotensive signifies a potential crisis that demands immediate nursing intervention. Restlessness and agitation can indicate anxiety, pain, or even inadequate oxygenation. Coupled with hypotension, which suggests that the patient's blood pressure is dangerously low, this combination creates a significant risk for complications.

Hypotension can lead to decreased organ perfusion and impaired tissue oxygenation, which may result in serious outcomes if not promptly addressed. Therefore, this clinical picture requires urgent assessment to determine the underlying cause and initiate appropriate interventions, such as administering fluids or medications to stabilize blood pressure and addressing any sources of agitation or discomfort.

In contrast, stable heart rate, minor pain, and a patient who is quiet and alone do not indicate an immediate threat to the patient's safety and condition. While they may warrant monitoring or intervention at some point, they do not require the same level of urgent response as the combination of restlessness and hypotension.