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 ["A","B","D","E"]
Explanation
A. Intimate partner violence (IPV) disproportionately affects certain populations, including women and marginalized groups. By routinely screening clients for IPV, nurses can identify those at risk and provide appropriate support, referrals to resources, and interventions. Addressing IPV can improve health outcomes by addressing physical and mental health consequences of abuse.
B. School performance can be influenced by various social determinants of health, including socioeconomic status, access to healthcare, and family dynamics. Inquiring about school performance allows nurses to identify potential issues affecting children's health and well-being. This information can guide referrals to educational resources, social services, or healthcare interventions to support children's academic success and overall health.
C. Older adults living in assisted living facilities can be vulnerable to neglect, abuse, or inadequate care. Assuming safety without assessment can overlook potential health disparities and risks faced by older adults. Nurses should routinely assess the living conditions, social supports, and healthcare needs of older adult clients to ensure they receive appropriate care and support, thus reducing disparities in care.
D. Gun violence disproportionately affects certain populations, including youth, minority communities, and those living in high-crime areas. Providing gun safety information upon request can help individuals make informed decisions about firearm ownership, storage, and safety practices. This education can contribute to reducing injuries and deaths related to firearms, thereby addressing disparities in injury prevention and public health.
E. Parenting support is crucial for promoting healthy child development and reducing disparities in children's health outcomes. Parents facing socioeconomic challenges, lack of access to resources, or social stressors may benefit significantly from parenting support. Providing information and resources in the emergency department can empower parents to navigate challenges effectively, enhancing their ability to provide a nurturing environment for their children.
Correct Answer is A
Explanation
A. Oral hypoglycemic medications are often prescribed to lower blood glucose levels in individuals with type 2 diabetes mellitus. They work by either increasing insulin production, improving insulin sensitivity, or reducing glucose production by the liver. These medications are typically considered when lifestyle modifications alone are insufficient to achieve target blood glucose levels.
B. Insulin therapy is considered in type 2 diabetes who cannot achieve adequate glucose control with oral medications alone.
C. Peritoneal dialysis is not typically indicated as a secondary prevention measure for diabetes mellitus. Peritoneal dialysis is a treatment for end-stage renal disease (ESRD) when the kidneys can no longer function effectively.
D. Fluid restrictions may be necessary in clients with advanced kidney disease (nephropathy) resulting from diabetes. However, fluid restrictions alone do not constitute a secondary prevention action for diabetes mellitus itself.
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