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 B
Explanation
A. This response addresses the timeframe for heparin to achieve therapeutic levels in the bloodstream, not its action on dissolving clots. Heparin works primarily by inhibiting the formation of new clots and preventing existing clots from enlarging or propagating, rather than directly dissolving existing clots.
B. This statement accurately describes the mechanism of action of heparin. Heparin is an anticoagulant that works by enhancing the activity of antithrombin III, which inhibits the clotting factors thrombin and factor Xa. This action prevents the formation of new clots and stabilizes existing clots, but it does not actively dissolve them.
C. While pharmacists are knowledgeable about medications, including their mechanisms of action, it is within the scope of nursing practice to provide information on how medications work to clients. The nurse should be prepared to explain the basic mechanism of heparin's action to the client in understandable terms.
D. This response is inaccurate regarding heparin's action. Heparin itself does not directly dissolve clots; it prevents further clot formation and allows the body's natural fibrinolytic (clot-dissolving) mechanisms to work on existing clots. Oral medications like warfarin or direct oral anticoagulants (DOACs) may be used after initial heparin therapy to continue anticoagulation, but they do not directly dissolve clots either.
Correct Answer is A
Explanation
A. A care coordinator role involves organizing and facilitating the delivery of healthcare services to ensure that the client's needs are met in a timely and efficient manner. This includes coordinating care plans, scheduling appointments, communicating between healthcare providers, and ensuring continuity of care. The nurse acts as a central point of contact and coordination for the client's healthcare team, ensuring all aspects of care are addressed.
B. A counselor role involves providing emotional support, guidance, and counseling to clients and their families. While nurses may provide counseling as part of their care, it typically focuses on health-related issues and coping strategies rather than organizing interprofessional teams.
C. An educator role involves providing information, teaching, and training to clients, families, and healthcare team members. Nurses educate clients about their health conditions, treatments, and self- care practices. They also educate other healthcare professionals on best practices, new treatments, and protocols. While education is crucial for effective teamwork, it alone does not encompass organizing interprofessional teams.
D. A researcher role involves conducting scientific inquiry and research to advance knowledge and improve healthcare practices. Researchers contribute to evidence-based practice by generating new knowledge through research studies. While research may influence healthcare teams' decisions and practices, it is not directly related to organizing interprofessional teams for client care.
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