During PACU recovery, a patient has BP 118/72, pulse 76, respirations 12, SpO2 91%, and is sleepy but awakens easily. Which action should the nurse take?

• A. Place the patient in a side-lying position.
• B. Encourage the patient to take deep breaths.
• C. Prepare to transfer the patient from the PACU.
• D. Increase the rate of the postoperative IV fluids.

Answer: (B)

The main idea is to support ventilation and oxygenation right after anesthesia. A SpO2 of 91% means the lungs aren’t exchanging gas as well as they should. The patient is sleepy but can wake up, so they can participate in breathing exercises. Encouraging deep breaths helps expand the alveoli, increases tidal volume, and recruits collapsed air spaces that anesthesia often creates. This improves oxygen uptake and helps raise the oxygen saturation back toward normal levels. Incentive or deliberate deep-breathing efforts are a direct, noninvasive way to reverse mild hypoxemia in the PACU.

Placing the patient on their side might help with airway patency occasionally, but it doesn’t address the underlying ventilation issue as effectively. Moving the patient out of the PACU is not appropriate while oxygenation is suboptimal, and simply increasing IV fluids doesn’t improve gas exchange and could lead to fluid overload.