What is the first action the nurse should take for a patient in the postanesthesia care unit with a blood pressure of 100/60 mm Hg?

The first action a nurse should take for a patient in the postanesthesia care unit with a blood pressure of 100/60 mm Hg is to check the medical record for the patient's baseline blood pressure. This step is crucial as it provides context about the patient's usual blood pressure range and allows the nurse to determine if the current reading is a concerning change or within acceptable limits.

Understanding the patient's baseline helps the nurse assess the significance of the blood pressure reading in relation to the patient’s overall condition. If the baseline blood pressure is generally higher, the current reading may indicate hypotension, which requires further evaluation. Conversely, if 100/60 mm Hg is common for that patient, it might not necessitate urgent interventions.

Once the baseline is established, the nurse can make informed decisions on subsequent actions, such as administering fluids, notifying the healthcare provider, or assessing for signs of shock, all of which might be necessary depending on the patient’s historical data. This systematic approach ensures that the care provided is tailored to the individual needs of the patient, enhancing safety and efficacy in postoperative management.