A patient is admitted to the postanesthesia care unit (PACU) with a blood pressure (BP) 122/72 mm Hg. Thirty minutes after admission, the BP is 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse is most appropriate?
Continue to take vital signs every 15 minutes.
Notify the anesthesia care provider (ACP).
Increase the postoperative IV fluid rate.
Administer oxygen therapy at 100% per mask.
The Correct Answer is A
A. Vital sign monitoring every 15 minutes is a standard practice in the postanesthesia care unit (PACU) to closely monitor the patient's hemodynamic status and response to anesthesia. However, in this scenario, the patient's blood pressure (BP) and other vital signs are within an acceptable range, and there are no signs of instability.
B. The patient's vital signs, including BP, pulse rate, and skin condition, are within normal limits. There are no indications of hemodynamic instability or adverse events.
C. There is no indication to increase the postoperative intravenous (IV) fluid rate based solely on the patient's stable vital signs and absence of signs of dehydration or hypovolemia. Increasing IV fluids without clinical indication may lead to fluid overload and potential complications.
D. The patient's oxygen saturation level is not provided in the scenario, and there are no signs or symptoms of respiratory distress or hypoxemia. Therefore, administering oxygen therapy at 100% per mask is not warranted at this time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A"]
Explanation
A. Protein-calorie malnutrition can lead to decreased tissue integrity and delayed wound healing, increasing the risk of pressure ulcer development due to compromised nutritional status.
B. Diabetes, especially when uncontrolled, can lead to poor circulation and neuropathy, which increases the risk of pressure ulcers. Hyperglycemia can also impair wound healing and compromise the immune response, further contributing to the risk.
C. Edema increases pressure on the skin and underlying tissues, impairing circulation and increasing the risk of pressure ulcers, especially in areas where there is constant pressure or friction against surfaces.
D. A client with postoperative delirium is not necessarily at risk of delirium.
E. A client post cardiac catheterization and already ambulating is not at risk of pressure sores
Correct Answer is B
Explanation
B. Alcohol consumption, especially beer and spirits, is associated with an increased risk of gout attacks as it can elevate uric acid levels in the body. Limiting alcohol intake can help prevent gout attacks.
A. While adequate hydration is important for overall health, limiting fluid intake to 1 liter per day may not be appropriate, especially considering that hydration can help prevent gout attacks.
C. While aspirin is commonly used for pain relief, it is not typically recommended for gout management.
D. High-purine foods such as red meat, organ meats, and certain seafood can exacerbate gout symptoms by increasing uric acid levels in the body. Therefore, closely following a high-purine diet would likely worsen gout symptoms rather than improve them.
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