A nurse is caring for a 35-year-old male client in the postanesthesia care unit (PACU) following a laparoscopic appendectomy. The client is drowsy and responsive to voice. As part of the assessment, the nurse must monitor the client’s status and respond to changes.

Exhibits

Complete the following sentence by using the lists of options:

The nurse should first address the client's
_
, followed by the client’s _
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}

The nurse should first address the client’s oxygen saturation, followed by the client’s blood pressure.

Addressing the oxygen saturation is crucial because the client’s level has dropped significantly to 86%, indicating potential respiratory distress or hypoxia. Following that, the nurse should address the blood pressure, which has also dropped, indicating possible hemodynamic instability.

Let’s break down the case notes to understand why addressing the client’s oxygen saturation and blood pressure is critical:

Oxygen Saturation

Initial Vital Signs (1200): The client’s oxygen saturation was 100% on 2 L oxygen via nasal cannula.
Current Vital Signs (1220): The oxygen saturation has dropped to 86% on the same oxygen support.

This significant drop in oxygen saturation indicates that the client is not receiving adequate oxygen, which can lead to hypoxia. Hypoxia can cause severe complications, including organ damage. Therefore, improving oxygenation is the top priority.

Blood Pressure

Initial Vital Signs (1200): The client’s blood pressure was 110/75 mm Hg.
Current Vital Signs (1220): The blood pressure has decreased to 90/60 mm Hg.

The drop in blood pressure suggests that the client is experiencing hemodynamic instability, which could be due to several factors, including dehydration, blood loss, or a reaction to anesthesia. Low blood pressure can lead to inadequate perfusion of vital organs, which is why it needs to be addressed promptly after stabilizing the oxygen saturation.

Other Symptoms

Muscle Rigidity: The client is experiencing painful muscle rigidity, which could be a sign of a serious condition like malignant hyperthermia, especially given the elevated temperature.
Temperature: The client’s temperature has spiked to 40.2°C (104.4°F), indicating a possible infection or reaction.
Heart Rate: The heart rate has increased to 125/min, which could be a compensatory response to low blood pressure and hypoxia.
Nausea and Vomiting: The client has vomited twice, which could contribute to dehydration and electrolyte imbalance.

Conclusion

By addressing the oxygen saturation first, the nurse ensures that the client is receiving adequate oxygen, which is essential for all bodily functions. Following that, stabilizing the blood pressure is crucial to ensure proper perfusion and prevent further complications.

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Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale
Ipratropium inhalers can potentially increase heart rate and blood pressure, but this is not a common side effect. The concern about high blood pressure is valid but not as critical as an allergy to atropine.
Choice B rationale
Using albuterol with ipratropium is common practice for managing bronchospasm. There is no contraindication for using both medications together.
Choice C rationale
An allergy to atropine is significant because ipratropium is chemically related to atropine. This could lead to a severe allergic reaction.
Choice D rationale
There are no known interactions between ipratropium and alcohol. However, it is always best to consult with a healthcare provider regarding alcohol consumption while on medication.

A. Monitor the client for weight gain. B. Monitor for hypoglycemia for 3 hr after pramlintide administration. C. Inject the pramlintide in the client’s upper arm. D. Administer pramlintide 30 min prior to a meal.

Correct Answer is B

Explanation

Choice A rationale
Weight gain is not a common side effect of pramlintide. Monitoring for hypoglycemia is more critical.
Choice B rationale
Pramlintide can cause hypoglycemia, especially within 3 hours after administration. Monitoring for hypoglycemia is essential.
Choice C rationale
Pramlintide should be injected into the abdomen or thigh, not the upper arm.
Choice D rationale
Pramlintide should be administered immediately before a meal, not 30 minutes prior.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is talking with a client who has a new prescription for an ipratropium inhaler to treat exercise-induced bronchospasm. Which of the following client statements should the nurse report to the provider?

Correct Answer is C

Explanation

A nurse is preparing to administer medications to a client who has type 1 diabetes mellitus. The client takes lispro insulin and has a new prescription for pramlintide. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who has hypertension and nephropathy due to type 2 diabetes mellitus. The nurse should expect to administer which of the following medications to slow the progression of the nephropathy?

A nurse is reviewing laboratory data for a client who is taking simvastatin to correct plasma lipid levels. Which of the following findings should the nurse identify as an adverse effect of this therapy?

A nurse is caring for a client who has hyperlipidemia and a new prescription for colesevelam. The nurse should monitor the client for which of the following manifestations as an adverse effect of colesevelam?

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A nurse is completing an admission assessment for a client who has been taking St. John’s wort. The nurse should identify that which of the following medications can interact with St. John’s wort?

A nurse is providing teaching to a client who has type 2 diabetes mellitus and is starting to take immediate-release exenatide. Which of the following client statements indicates an understanding of the teaching?

A nurse is assessing a client who has heart failure and is taking digoxin. Which of the following manifestations should the nurse report to the provider as an indication of digoxin toxicity?

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