Following surgery for removal of a brain tumor, a client is coughing, short of breath, and has a “bad” feeling. The nurse obtains the following vital signs: blood pressure of 80/60 mm Hg, pulse rate...

Following surgery for removal of a brain tumor, a client is coughing, short of breath, and has a “bad” feeling. The nurse obtains the following vital signs: blood pressure of 80/60 mm Hg, pulse rate of 120 bpm, and respiratory rate of 30 shallow breaths/min. What should the nurse do first?

1. Call the neurosurgeon.

2. Place the client in the Trendelenburg position.

3. Consult the neurologic Clinical Nurse Specialist (CNS).

4. Activate the rapid response team (RRT).