A nurse is assessing a client who has a long history of smoking and suspected of having laryngeal cancer. The nurse should anticipate that the client will report that her earliest manifestation was

A. A decrease in systolic blood pressure from 140 mm Hg to 120 mm Hg could indicate hypotension. Postoperatively, especially after receiving a spinal anesthetic, hypotension can occur due to vasodilation or decreased sympathetic tone. This change in blood pressure warrants notification of the provider because significant hypotension can lead to inadequate perfusion to vital organs and tissues.
B. A slight increase in temperature from 37.2°C to 37.5°C (99.0°F to 99.5°F) is a mild elevation and may not necessarily require immediate notification unless accompanied by other signs of infection or instability. It could be related to the stress response post-surgery. However, if there are other concerning signs (e.g., increased heart rate, worsening pain), the nurse should reassess and consider further action.

C. A decrease in pulse oximetry from 98% to 96% indicates a mild decrease in oxygen saturation. While this change alone may not be alarming, the nurse should assess the client's respiratory status and potential causes (e.g., positioning, respiratory depression from anesthesia). Oxygen saturation levels below 95% generally require intervention, but 96% is still within a normal range for most clients.
D. An increase in pain from 4/10 to 6/10 indicates worsening pain. Postoperatively, increasing pain may indicate inadequate pain management, worsening condition at the surgical site, or other complications such as hematoma or infection.

A. An N-95 respirator is designed to filter out airborne particles and is used primarily for protection against airborne diseases such as tuberculosis or certain respiratory infections like COVID-19. It is not necessary for contact precautions unless there is also a risk of airborne transmission.

B. Goggles protect the eyes from splashes, sprays, or droplets of infectious material. They are not typically required for routine contact precautions unless there is a risk of splashes or sprays to the eyes.
C. Gloves are essential for contact precautions. They protect the nurse's hands from direct contact with potentially infectious material on the client's bed linen or any contaminated surfaces. Gloves should be worn when handling soiled linen and removed and discarded appropriately after use.
D. A face shield provides full-face protection against splashes, sprays, or splatters of infectious material. It is particularly useful when there is a risk of exposure to bodily fluids or during procedures that may generate splashes. While not always required for routine contact precautions, it may be used depending on the specific situation, such as when cleaning surfaces heavily contaminated with body fluids.