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.

Answer and Explanation

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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Correct Answer is D

Explanation

D. Excessive thyroid hormone replacement therapy, leading to hyperthyroidism, can accelerate bone turnover and increase the risk of osteoporosis. Hyperthyroidism can disrupt normal bone remodeling processes, leading to decreased bone mineral density and increased fracture risk.

A. NSAIDs are commonly used to reduce inflammation and relieve pain. While short-term or occasional use of NSAIDs is generally safe, long-term use or high doses of NSAIDs may be associated with an increased risk of osteoporosis and bone fractures.

B. Anticoagulants, such as warfarin and heparin, are medications used to prevent blood clot formation. While anticoagulants themselves are not directly associated with osteoporosis risk, prolonged immobilization due to conditions requiring anticoagulation therapy (such as deep vein thrombosis or pulmonary embolism) can increase the risk of osteoporosis and bone loss due to decreased weight- bearing activity.

C. Cardiac glycosides, such as digoxin, are medications used to treat heart failure and certain cardiac arrhythmias. There is no direct evidence to suggest that cardiac glycosides themselves are a risk factor for osteoporosis.

A. A client who has protein calorie malnutrition B. A client who has type1 diabetes mellitus and is hyperglycemic C. A client who has right-sided heart failure and 4+ edema to the lower extremities D. A client who has postoperative delirium E. A client who is ambulatory following a cardiac catheterization 4 hr ago

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

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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