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 A

Explanation

A. Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a significant concern following knee replacement surgery due to the increased risk of blood clot formation associated with immobility and surgery. Limited mobility can predispose the patient to stasis of blood flow, which increases the risk of VTE.

B. While fluid and electrolyte imbalance can occur postoperatively, especially if the patient experiences complications such as excessive bleeding or fluid shifts, limited mobility alone is less likely to directly lead to this complication as a priority.

C. Limited mobility can potentially impact surgical wound healing by delaying the resolution of edema, impairing circulation, and increasing the risk of infection. However, this complication may not be as immediate or life-threatening as others on the list.

D. Hypovolemic shock, characterized by inadequate tissue perfusion due to decreased circulating blood volume, is a severe complication that can result from significant blood loss. While bleeding can occur postoperatively, it is less common as a complication of knee replacement surgery, especially within the first few days.

A. Teach the patient to push the button every 10 minutes for an hour before going to sleep, even if the pain is minimal. B. Request that the health care provider order a bolus dose of morphine to be given when the patient awakens with pain. C. Consult with the health care provider about using a different treatment protocol to control the patient's pain. D. Administer a dose of morphine every 1 to 2 hours from the PCA machine while the patient is sleeping.

Correct Answer is C

Explanation

C. This option is appropriate as the current treatment protocol is not effectively managing the patient's pain. The nurse can collaborate with the healthcare provider to reassess the patient's pain management needs and explore alternative strategies or adjustments to the PCA regimen.

A. This approach may lead to overmedication and increase the risk of adverse effects such as respiratory depression or sedation.

B. Requesting a bolus dose when the patient awakens with pain could be a part of the solution, but it should be carefully evaluated within the context of the overall pain management plan.

D. Administering scheduled doses of morphine from the PCA machine without the patient's input or based solely on time intervals is not recommended.

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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

An older patient who had knee replacement surgery 2 days ago can only tolerate being out of bed with physical therapy twice a day. Which potential complication should the nurse identify as a priority for this patient?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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