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

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. This scenario describes a near-miss or a close call, where an error occurred but was intercepted before reaching the patient. While it is a significant incident that requires investigation and corrective action, it does not meet the criteria for a sentinel event because there was no actual harm to the patient.
B. This option could be related to the natural course of the patient's illness or underlying condition.
C. This incident involves a medication error where a potentially harmful medication was prescribed but not administered due to cancellation. Since the medication was not administered and no harm occurred to the patient, this does not meet the criteria for a sentinel event. It is a medication error that warrants investigation and review to prevent future occurrences.
D. This is because patient falls are specifically mentioned as one of the most commonly reported sentinel events, which can result in serious injury or death.

Correct Answer is ["5.6"]

Explanation

Convert the weight from pounds to kilograms: 1 kilogram equals 2.2 pounds. The toddler weighs 33 lb, which is approximately 15 kg (33 ÷ 2.2).
The prescribed dose is 30 mg/kg/day, so for a 15 kg toddler, that's 450 mg/day (15 kg × 30 mg/kg).

This total daily dose should be divided into two doses administered every 12 hours, which equals 225 mg per dose (450 mg ÷ 2).

Now, using the concentration of the amoxicillin suspension available, which is 200 mg/5 mL, calculate the volume of suspension needed to deliver a dose of 225 mg.

200 mg/5 mL = 225 mg/x mL, solving for x gives us 5.625 mL.

=Therefore, the nurse should administer 5.6 mL of the amoxicillin suspension every 12 hours to the toddler.

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is providing an in-service to a group of staff nurses about unexpected events. Which of the following should the nurse include in the teaching as an example of a sentinel event?

Correct Answer is D

Explanation

Correct Answer is ["5.6"]

Explanation

A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first?

A nurse is teaching a newly licensed nurse about reducing the risk of needlestick injuries. Which of the following instructions should the nurse include?

A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when he identifies which of the following as manifestations of hypoglycemia? (Select all that apply.)

A nurse should identify which of the following as ways to make a positive impact in reducing health disparities in the clients they care for?

A nurse is reviewing a client's medical record. Which of the following findings should the nurse identify as a fall risk?

A nurse reports an incident of suspected child abuse. One of the parents of the child becomes upset and demands to know the reason for the nurse's action. Which of the following responses by the nurse is appropriate?