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.
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Related Questions
Correct Answer is D
Explanation
D. Atorvastatin is a statin medication used to lower cholesterol levels and reduce the risk of cardiovascular events. Statins, including atorvastatin, have been associated with an increased risk of rhabdomyolysis, particularly when used in high doses or in combination with other medications that can interact to increase statin levels in the blood.
A. There is no direct evidence to suggest that omeprazole increases the risk of rhabdomyolysis when used in combination with colchicine.
B. There is limited evidence to suggest that hydrochlorothiazide significantly increases the risk of rhabdomyolysis when used in combination with colchicine.
C. There is no direct evidence to suggest that carvedilol increases the risk of rhabdomyolysis when used in combination with colchicine.
Correct Answer is B
Explanation
B. Muscle spasms can sometimes be triggered or exacerbated by poor positioning or pressure on certain areas of the body. Realigning the client's position will help relieve muscle spasms by reducing pressure or tension on the affected muscles.
A. Adjusting the weight amount in traction may help alleviate pain and muscle spasms by reducing tension on the affected limb. However, realignment should be done first.
C. Muscle relaxants can help alleviate muscle spasms and associated pain by reducing muscle tone and tension. However, realignment should be done first.
D. Opioid analgesics are potent pain relievers that can effectively manage moderate to severe pain, including pain from muscle spasms. However, that should not be the first intervention.
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