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. Diazepam is a benzodiazepine commonly used in the management of alcohol withdrawal syndrome. Benzodiazepines are effective in reducing symptoms such as anxiety, tremors, agitation, and preventing seizures that can occur during alcohol withdrawal. Diazepam is preferred due to its rapid onset and long duration of action, which helps stabilize the client during withdrawal.
B. Buprenorphine is a partial opioid agonist typically used in the treatment of opioid dependence, not alcohol withdrawal. It is not recommended as a first-line medication for alcohol withdrawal management.
C. Disulfiram is used as an aversive therapy in the treatment of alcohol use disorder. It works by causing unpleasant symptoms (such as nausea, vomiting, palpitations) if the client consumes alcohol. It is not indicated for the treatment of alcohol withdrawal symptoms.
D. Methadone is a synthetic opioid agonist primarily used for the treatment of opioid dependence and chronic pain management. It has no role in the treatment of alcohol withdrawal and is not appropriate for managing symptoms associated with alcohol withdrawal.
Correct Answer is ["A","B","C","D"]
Explanation
Blood pressure 86/46 mm Hg
A blood pressure of 86/46 mm Hg indicates hypotension. Hypotension can be a sign of inadequate perfusion and may lead to organ dysfunction if not promptly addressed. Immediate action may include reassessment of the client's hemodynamic status, fluid resuscitation if indicated, and consideration of vasopressor medications under provider orders.
Oxygen saturation 94% on 2 L via nasal cannula
Although the oxygen saturation of 94% is within the acceptable range (typically ≥ 92% for most clients),
it should be monitored closely as per the prescribed titration to maintain ≥ 92%. If the oxygen saturation drops below the target range, the nurse may need to adjust the oxygen flow rate or consider alternative oxygen delivery methods to ensure adequate oxygenation.
Prescription for the transfusion of 2 units of packed RBCs
Transfusion of packed red blood cells (RBCs) is indicated, suggesting the client may have significant anemia or ongoing bleeding requiring correction of hemoglobin levels. Immediate action involves verifying the blood product compatibility, initiating transfusion per protocol (including pre-transfusion assessments), and monitoring the client closely for any signs of transfusion reaction or complications during the transfusion.
Pulse rate 100/min, respiratory rate 28/min
Elevated pulse rate (tachycardia) and respiratory rate (tachypnea) can indicate physiological stress, inadequate oxygenation, or compensation for decreased cardiac output due to hypotension. These vital signs should be closely monitored for any worsening trends or signs of instability that may require immediate intervention, such as further assessment for hypovolemia or respiratory distress.
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