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. Cyclosporine is typically taken on an empty stomach, either 1 hour before or 2 hours after a meal, to improve absorption. Taking it with food, especially high-fat meals, can decrease absorption and effectiveness.

A. Grapefruit juice can interact with cyclosporine, leading to increased blood levels of the medication and potentially causing toxicity. Therefore, clients should be advised to avoid grapefruit juice when taking cyclosporine.

B. Mixing cyclosporine oral solution with chocolate milk or any other liquid should be done only if directed by the healthcare provider or as specified in the medication instructions.

C. Using a plastic container to mix the oral solution may reduce the risk of interaction compared to using metal or glass containers. However, it's important to follow the specific instructions provided with the medication.

A. Teach the client which positions to avoid during PT. B. Identify the client's pain level and medicate if needed. C. Perform the client's morning care. D. Encourage the client to use full weight bearing.

Correct Answer is B

Explanation

B. Assessing the client's pain level is crucial, especially before physical therapy, as pain can affect participation and compliance with therapy. If the client is experiencing pain, appropriate pain management measures should be implemented before PT to optimize participation and comfort.

A. The nurse should educate the client on proper body mechanics and positions to avoid during physical therapy to promote safe movement and prevent complications. However, this is not a priority.

C. While morning care is important for maintaining hygiene and comfort, it may not be the priority at this specific time, especially if the client is scheduled for physical therapy soon.

D. Encouraging full weight bearing immediately postoperative may not be appropriate, as the surgical site needs time to heal and regain strength.

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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

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