A client is 4 hours post-abdominal surgery. The nurse notes the client's blood pressure is 90/50 mmHg, heart rate is 110 beats per minute, and urine output is 20 mL over the last hour. What is the most important initial nursing action?

Question: A client is 4 hours post-abdominal surgery. The nurse notes the client's blood pressure is 90/50 mmHg, heart rate is 110 beats per minute, and urine output is 20 mL over the last hour. What is the most important initial nursing action?

Answer options:

• Administer the prescribed PRN opioid for pain.
• Reposition the client to a Fowler's position.
• Increase the rate of the maintenance intravenous fluids. ✅ Assess for signs of internal bleeding or hypovolemic shock.

Correct answer: Assess for signs of internal bleeding or hypovolemic shock.

Explanation: The client's vital signs (hypotension, tachycardia) and low urine output are indicative of potential hypovolemia or hemorrhage, which are serious post-operative complications. The nurse's immediate priority is to assess for the underlying cause, such as internal bleeding or hypovolemic shock, before implementing other interventions.