A patient presents with systolic blood pressure 86 mmHg, tachycardia, and cool clammy skin after surgery. What is the immediate nursing action?

• A. Administer a rapid IV vasopressor without assessment.
• B. Document vital signs and wait for orders.
• C. Assess airway, breathing, and circulation; call for help and initiate IV fluid resuscitation per protocol.
• D. Provide analgesia and monitor.

Answer: (C)

When a postoperative patient is hypotensive with tachycardia and cool, clammy skin, the priority is to address shock and restore perfusion. The immediate action is to assess airway, breathing, and circulation, because ensuring a patent airway and adequate breathing is foundational to oxygen delivery, while rapid assessment of circulation guides urgent interventions. Call for help and activate the rapid response, then initiate IV fluid resuscitation per protocol to restore intravascular volume and improve perfusion. This approach targets the most likely issue—hemorrhagic or hypovolemic shock from blood loss—while you continue to monitor vitals, assess signs of ongoing bleeding, and prepare for further treatment (such as blood products) as indicated. Administering a vasopressor without orders or delaying action by merely documenting vitals would not correct the instability, and analgesia would not address the underlying hemodynamic crisis.