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 D

Explanation

Choice A rationale
Hyperglycemia is not a common adverse effect of colesevelam. Colesevelam is primarily used to lower cholesterol levels and can also help control blood sugar levels in patients with type 2 diabetes.
Choice B rationale
Stomatitis, or inflammation of the mouth, is not typically associated with colesevelam. This medication works in the intestines and is not absorbed into the bloodstream, so it does not commonly cause systemic side effects.
Choice C rationale
Fever is not a known adverse effect of colesevelam. The medication’s side effects are generally limited to the gastrointestinal system.
Choice D rationale
Constipation is a common adverse effect of colesevelam. This medication binds to bile acids in the intestines, which can lead to gastrointestinal side effects such as constipation.

A. Take this medication with meals. B. Reduce dietary fiber while taking the medication. C. Administer an antacid with the medication. D. Increase fluid intake while taking the medication.

Correct Answer is D

Explanation

Choice A rationale
Sucralfate should be taken on an empty stomach, not with meals, to ensure it coats the ulcer effectively.
Choice B rationale
There is no need to reduce dietary fiber while taking sucralfate. Fiber intake does not interfere with the medication’s effectiveness.
Choice C rationale
Antacids should not be taken within 30 minutes before or after taking sucralfate, as they can interfere with its action.
Choice D rationale
Increasing fluid intake is recommended while taking sucralfate to help prevent constipation, a common side effect of the medication.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has hyperlipidemia and a new prescription for colesevelam. The nurse should monitor the client for which of the following manifestations as an adverse effect of colesevelam?

Correct Answer is D

Explanation

A nurse is providing teaching to a client who has a duodenal ulcer and is starting to take sucralfate. Which of the following instructions should the nurse include in the teaching?

Correct Answer is D

Explanation

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