A nurse is caring for an older adult client who has just returned from PACU after receiving a spinal anesthetic during knee surgery. For which of the following findings should the nurse notify the provider?
Systolic blood pressure changed from 140 mm Hg to 120 mm Hg
Temperature changed from 37.2° C (99.0° F) to 37.5° C (99.5° F)
Pulse oximetry changed from 98% to 96%
Client reports knee pain, changed from 4/10 to 6/10
The Correct Answer is A
A. A decrease in systolic blood pressure from 140 mm Hg to 120 mm Hg could indicate hypotension. Postoperatively, especially after receiving a spinal anesthetic, hypotension can occur due to vasodilation or decreased sympathetic tone. This change in blood pressure warrants notification of the provider because significant hypotension can lead to inadequate perfusion to vital organs and tissues.
B. A slight increase in temperature from 37.2°C to 37.5°C (99.0°F to 99.5°F) is a mild elevation and may not necessarily require immediate notification unless accompanied by other signs of infection or instability. It could be related to the stress response post-surgery. However, if there are other concerning signs (e.g., increased heart rate, worsening pain), the nurse should reassess and consider further action.
C. A decrease in pulse oximetry from 98% to 96% indicates a mild decrease in oxygen saturation. While this change alone may not be alarming, the nurse should assess the client's respiratory status and potential causes (e.g., positioning, respiratory depression from anesthesia). Oxygen saturation levels below 95% generally require intervention, but 96% is still within a normal range for most clients.
D. An increase in pain from 4/10 to 6/10 indicates worsening pain. Postoperatively, increasing pain may indicate inadequate pain management, worsening condition at the surgical site, or other complications such as hematoma or infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. An N-95 respirator is designed to filter out airborne particles and is used primarily for protection against airborne diseases such as tuberculosis or certain respiratory infections like COVID-19. It is not necessary for contact precautions unless there is also a risk of airborne transmission.
B. Goggles protect the eyes from splashes, sprays, or droplets of infectious material. They are not typically required for routine contact precautions unless there is a risk of splashes or sprays to the eyes.
C. Gloves are essential for contact precautions. They protect the nurse's hands from direct contact with potentially infectious material on the client's bed linen or any contaminated surfaces. Gloves should be worn when handling soiled linen and removed and discarded appropriately after use.
D. A face shield provides full-face protection against splashes, sprays, or splatters of infectious material. It is particularly useful when there is a risk of exposure to bodily fluids or during procedures that may generate splashes. While not always required for routine contact precautions, it may be used depending on the specific situation, such as when cleaning surfaces heavily contaminated with body fluids.
Correct Answer is ["A","C","E"]
Explanation
A. This disease is caused by the varicella-zoster virus and is transmitted via airborne particles. When an infected person coughs or sneezes, the virus can be inhaled by others.
B. This bacterium causes severe diarrhea and colitis. It is primarily transmitted through contact with contaminated surfaces or feces, not through the air.
C. Measles is a highly contagious viral disease that spreads through airborne transmission. The virus can linger in the air for up to two hours after an infected person coughs or sneezes.
D. This bacterium can cause various infections, including skin infections and pneumonia. It is mainly spread through direct contact with an infected person or contaminated surfaces, not through the air.
E. Caused by the bacterium Mycobacterium tuberculosis, TB is transmitted through airborne particles. When a person with active TB coughs, sneezes, or talks, the bacteria can be inhaled by others.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.