The nurse assesses an adult client 24 hours following abdominal surgery and finds the client's blood pressure is 98/40 mm Hg. The client is tachycardic, restless, and irritable. Which action should the nurse perform first?

Rationale: A. Check under the back for evidence of bleeding: Hypotension, tachycardia, restlessness, and irritability 24 hours post-abdominal surgery suggest possible hypovolemic shock due to internal bleeding. The nurse’s first action is to assess for a source of blood loss to initiate prompt intervention. B. Ensure the IV solution is infusing at the prescribed rate: Maintaining IV access is important for fluid resuscitation, but identifying the cause of hypotension takes priority. Confirming infusion rate alone does not address potential acute hemorrhage. C. Notify the healthcare provider of the findings: Reporting the client’s condition is necessary, but immediate assessment of bleeding comes first to provide accurate information and allow timely intervention. D. Listen to lung sounds: Assessing lung sounds is part of a broader evaluation, but respiratory assessment does not take precedence over identifying life-threatening hemorrhage in a post-surgical client.