The nurse is assessing the status of a post-operative client in the PACU. The nurse should be most concerned with which assessment finding?
Blood pressure 110/70
heart rate 86
Hypoactive bowel sounds
Increased restlessness
Negative Homan's sign
Correct Answer : D
a. Blood pressure 110/70: This is within normal range for many individuals and is not immediately concerning in the post-operative context.
b. heart rate 86: This is a normal heart rate for most individuals and is not concerning post-operatively.
c. Hypoactive bowel sounds: Hypoactive bowel sounds are common post-operatively due to anesthesia and are not immediately concerning.
d. Increased restlessness Increased restlessness can be a sign of pain, anxiety, hypoxia, or other complications and should be addressed promptly.
e. Negative Homan's sign: A negative Homan’s sign indicates no apparent deep vein thrombosis and is a positive finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
a. Diphenhydramine: Diphenhydramine is an antihistamine that can also be used for its sedative properties to help calm an agitated client.
b. Ondansetron: Ondansetron is an antiemetic used to prevent nausea and vomiting, not for managing agitation or assaultive behavior. The nurse should question this order as it is not appropriate for the client's current symptoms.
c. Lorazepam: Lorazepam is a benzodiazepine used for its anxiolytic and sedative effects, making it appropriate for calming an agitated client.
d. Haloperidol: Haloperidol is an antipsychotic medication commonly used to manage severe agitation and aggressive behavior.
Correct Answer is C
Explanation
a. Administer the 6mg Benztropine orally with a full glass of water on an empty stomach: Benztropine is an anticholinergic medication used to manage the extrapyramidal side effects (EPS) of antipsychotics. However, it's important to consult the healthcare provider before administering any additional medications.
b. Ask the healthcare provider to increase the dose of Haloperidol to assist with the side effect: Increasing the dose of Haloperidol might worsen the tardive dyskinesia symptoms.
c. Hold the dose of Haloperidol and notify the healthcare provider. (Correct) Haloperidol is an antipsychotic medication with a known side effect of tardive dyskinesia, which manifests as involuntary facial and body movements. Stopping the medication and informing the provider is crucial to determine the best course of action, which might involve dose adjustment or switching medications
d. Explain to the client that the side effects should diminish in one to two weeks: Tardive dyskinesia can be a persistent side effect, and reassurance without addressing the medication is not helpful.
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