A nurse is caring for a 35-year-old male client in the postanesthesia care unit (PACU) following a laparoscopic appendectomy. The client is drowsy and responsive to voice. As part of the assessment, the nurse must monitor the client’s status and respond to changes.

Exhibits

Complete the following sentence by using the lists of options:

The nurse should first address the client's
_
, followed by the client’s _
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}

The nurse should first address the client’s oxygen saturation, followed by the client’s blood pressure.

Addressing the oxygen saturation is crucial because the client’s level has dropped significantly to 86%, indicating potential respiratory distress or hypoxia. Following that, the nurse should address the blood pressure, which has also dropped, indicating possible hemodynamic instability.

Let’s break down the case notes to understand why addressing the client’s oxygen saturation and blood pressure is critical:

Oxygen Saturation

Initial Vital Signs (1200): The client’s oxygen saturation was 100% on 2 L oxygen via nasal cannula.
Current Vital Signs (1220): The oxygen saturation has dropped to 86% on the same oxygen support.

This significant drop in oxygen saturation indicates that the client is not receiving adequate oxygen, which can lead to hypoxia. Hypoxia can cause severe complications, including organ damage. Therefore, improving oxygenation is the top priority.

Blood Pressure

Initial Vital Signs (1200): The client’s blood pressure was 110/75 mm Hg.
Current Vital Signs (1220): The blood pressure has decreased to 90/60 mm Hg.

The drop in blood pressure suggests that the client is experiencing hemodynamic instability, which could be due to several factors, including dehydration, blood loss, or a reaction to anesthesia. Low blood pressure can lead to inadequate perfusion of vital organs, which is why it needs to be addressed promptly after stabilizing the oxygen saturation.

Other Symptoms

Muscle Rigidity: The client is experiencing painful muscle rigidity, which could be a sign of a serious condition like malignant hyperthermia, especially given the elevated temperature.
Temperature: The client’s temperature has spiked to 40.2°C (104.4°F), indicating a possible infection or reaction.
Heart Rate: The heart rate has increased to 125/min, which could be a compensatory response to low blood pressure and hypoxia.
Nausea and Vomiting: The client has vomited twice, which could contribute to dehydration and electrolyte imbalance.

Conclusion

By addressing the oxygen saturation first, the nurse ensures that the client is receiving adequate oxygen, which is essential for all bodily functions. Following that, stabilizing the blood pressure is crucial to ensure proper perfusion and prevent further complications.

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Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale
Crushing tadalafil is not recommended as it can alter the medication’s effectiveness and absorption. Tadalafil should be taken whole to ensure proper dosage and efficacy.
Choice B rationale
Tadalafil can decrease blood pressure by relaxing blood vessels, which allows for increased blood flow. This is a known effect of phosphodiesterase type 5 (PDE5) inhibitors like tadalafil.
Choice C rationale
Tadalafil should not be taken more than once a day. Taking it twice a day can increase the risk of side effects and is not recommended.
Choice D rationale
The effects of tadalafil can last up to 36 hours, not just 4 hours. This prolonged duration is one of the reasons it is preferred by some patients.

A. Hypercalcemia. B. Hypotension. C. Hypokalemia. D. Hypernatremia. E. Hypoglycemia.

Correct Answer is E

Explanation

Choice A rationale
Hypercalcemia is not typically a risk in the emergency department unless the patient has a specific condition that causes elevated calcium levels.
Choice B rationale
Hypotension can occur in the emergency department, especially in cases of shock or severe dehydration, but it is not the most common risk.
Choice C rationale
Hypokalemia can occur, particularly in patients with certain medical conditions or those taking diuretics, but it is not the most common risk.
Choice D rationale
Hypernatremia can occur, especially in patients with dehydration or certain medical conditions, but it is not the most common risk.
Choice E rationale
Hypoglycemia is a common risk in the emergency department, especially in patients with diabetes or those who have not eaten for an extended period.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who has erectile dysfunction and has a new prescription for tadalafil. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is caring for a client in the emergency department. The client is at risk for developing which of the following conditions?

Correct Answer is E

Explanation

A nurse is administering bumetanide to a client who has ascites. The nurse should recognize that which of the following findings is an expected therapeutic effect of this medication?

A nurse is providing teaching to a client who has angina and a new prescription for nitroglycerin tablets. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a client who has been taking captopril for one year. Which of the following laboratory values should the nurse review? (Select all that apply.)

A nurse is teaching a client who has a new prescription for benzonatate. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is assessing a client who is receiving gemfibrozil. The nurse should identify which of the following findings as an adverse effect of this medication?

A nurse is preparing to administer medications to a client who has type 1 diabetes mellitus. The client takes lispro insulin and has a new prescription for pramlintide. Which of the following actions should the nurse take?

A nurse is caring for a client who received excessive IV fluids in error. Which of the following actions should the nurse take? (Select all that apply.)