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
Explanation
A. Glipizide belongs to a class of medications called sulfonylureas. Sulfonylureas work by stimulating the beta cells in the pancreas to release insulin. Insulin is a hormone that helps lower blood sugar levels by facilitating the uptake of glucose into cells for energy or storage. Therefore, this statement accurately describes the mechanism of action of glipizide.
B. Glipizide does not absorb carbohydrates. Instead, it acts on pancreatic beta cells to increase insulin secretion in response to glucose in the bloodstream.
C. Glipizide does not affect the liver's breakdown of insulin. Its primary action is on the pancreas to stimulate insulin release.
D. Glipizide does not replace insulin. It stimulates the pancreas to release more insulin. It is used in type 2 diabetes mellitus, where insulin production by the pancreas may be reduced but not absent.
Correct Answer is ["A","B","C","E"]
Explanation
A. Ventilator-associated pneumonia (VAP) is a common HAI that occurs in patients who have been mechanically ventilated for an extended period. The presence of a ventilator increases the risk of introducing pathogens into the lower respiratory tract, leading to pneumonia.
B. Catheter-associated urinary tract infection (CAUTI) is an HAI that occurs due to the use of urinary catheters. Indwelling urinary catheters can introduce bacteria into the urinary tract, increasing the risk of infection.
C. Surgical site infections (SSIs) are infections that occur after surgery in the part of the body where the surgery took place. They are a significant cause of morbidity and mortality and are considered HAIs when they occur in healthcare settings.
D. Influenza acquired from a coworker is not typically considered a healthcare-associated infection. It is usually acquired in community settings rather than healthcare facilities.
E. Central line-associated bloodstream infections (CLABSIs) occur when bacteria or other pathogens enter the bloodstream through a central venous catheter. These infections are considered HAIs because they are associated with the presence of a central venous catheter used for medical treatment.
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