A nurse in a PACU is caring for a client who is postoperative. Which of the following findings should the nurse report to the provider?
Capillary refill is less than 1 second.
Presence of a pulse deficit.
Systolic blood pressure is 10 points lower than before surgery.
Pulse oximetry is at 96%.
The Correct Answer is B
Choice A rationale:
A capillary refill of less than 1 second is a normal finding and indicates adequate peripheral perfusion. It is not a cause for concern in this postoperative client.
Choice B rationale:
The presence of a pulse deficit should be reported to the provider because it suggests a discrepancy between the apical and radial pulses, indicating potential cardiovascular compromise or inadequate arterial perfusion.
Choice C rationale:
A systolic blood pressure 10 points lower than before surgery can be a normal response to anesthesia or surgery and may not necessarily require immediate reporting unless accompanied by other concerning symptoms or vital sign abnormalities.
Choice D rationale:
Pulse oximetry at 96% is within the normal range for oxygen saturation and does not warrant immediate reporting. However, if the client is experiencing respiratory distress or other concerning symptoms, it should be addressed promptly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
High lipase is not a typical laboratory finding related to overusing prescribed diuretics and a sodium level of 127 mEq/L. Lipase is an enzyme involved in lipid digestion and is more relevant in assessing pancreatic function.
Choice B rationale:
High creatine kinase-MB (CK-MB) is not associated with overusing prescribed diuretics or hyponatremia (low sodium level). CK-MB is a specific marker for myocardial damage and is usually elevated in conditions like myocardial infarction.
Choice C rationale:
Low hemoglobin is not directly related to overusing prescribed diuretics and a sodium level of 127 mEq/L. Low hemoglobin may indicate anemia or other hematological issues but this is not a typical finding in this scenario.
Choice D rationale:
The correct answer is low urine specific gravity. Overusing diuretics can lead to excessive urination, causing the urine to become more dilute with lower specific gravity. A low urine specific gravity indicates decreased urine concentration and can be a sign of fluid and electrolyte imbalances, including hyponatremia.
Correct Answer is A
Explanation
Choice A rationale:
Completely irrigating one eye before irrigating the second eye is the correct action to take when a client receives a chemical splash on their face. This approach helps prevent the potential spread of the chemical from one eye to the other. Irrigation should be done immediately to flush out the chemical and minimize its harmful effects.
Choice B rationale:
Informing the client to blink their eyes rapidly during the irrigation process is not recommended. Blinking may exacerbate the dispersion of the chemical and could lead to further damage to the eyes. Instead, the client should keep their eyes open during irrigation.
Choice C rationale:
Delaying the irrigation process until the type of chemical in the eyes is identified is not appropriate. Time is critical in minimizing the impact of the chemical on the eyes. Immediate irrigation is essential, regardless of the type of chemical, to remove the substance from the eyes.
Choice D rationale:
Asking the client to count the number of fingers held up by the nurse before irrigating their eyes is not relevant in this situation. The priority is to initiate immediate irrigation to remove the chemical from the eyes. Assessing the client's visual acuity can be done later in the evaluation process after the eyes have been irrigated.
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