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 ["C","E"]

Explanation

Choice A rationale
Glucose levels are not typically monitored for patients receiving gentamicin.
Choice B rationale
Prothrombin time is not typically monitored for patients receiving gentamicin.
Choice C rationale
Serum creatinine should be monitored because gentamicin can cause nephrotoxicity, and elevated serum creatinine levels can indicate kidney damage.
Choice D rationale
Cardiac enzymes are not typically monitored for patients receiving gentamicin.
Choice E rationale
WBC count should be monitored because gentamicin can cause leukopenia or other changes in white blood cell counts.

Correct Answer is ["2"]

Explanation

Step 1 is to determine the volume of ketorolac to administer. Given: Dose required: 30 mg Concentration: 15 mg/mL Step 1: Calculate the volume to administer: 30 mg ÷ 15 mg/mL = 2 mL The nurse should administer 2 mL of ketorolac.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client receiving an intermittent IV bolus of gentamicin twice daily. Which of the following laboratory values should the nurse monitor while the client is receiving this medication? (Select all that apply.)

Correct Answer is ["C","E"]

Explanation

A nurse is preparing to administer ketorolac 30 mg IM to a client who is postoperative. Available is ketorolac 15 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["2"]

Explanation

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