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

Explanation

The nurse should first address the client’s elevated temperature followed by administering fluids.

So, the complete sentence would be: The nurse should first address the client’s elevated temperature followed by administering fluids.

Certainly! Let’s break down the situation and the rationale behind the priorities:

Elevated Temperature

The client’s temperature spiked significantly from 36.7°C (98.1°F) to 40.2°C (104.4°F) within a short period. This rapid increase is concerning for several reasons:

Risk of Hyperthermia: A temperature of 40.2°C is dangerously high and can lead to hyperthermia, which can cause damage to body tissues and organs if not promptly addressed.
Signs of Infection or Sepsis: Such a high fever could indicate a postoperative infection or sepsis, both of which require immediate attention.
Physiological Stress: Elevated temperatures increase metabolic demands, which can exacerbate other symptoms like tachycardia (high heart rate) and hypotension (low blood pressure).

Administering Fluids

After addressing the elevated temperature, the next priority is to administer fluids. Here’s why:

Hypotension (Low Blood Pressure): The client’s blood pressure dropped from 110/75 mm Hg to 90/60 mm Hg. This hypotension could be due to several factors, including dehydration, fever, or a systemic inflammatory response.
Tachycardia (High Heart Rate): The client’s heart rate increased from 65/min to 125/min. This could be a compensatory mechanism for the low blood pressure or a response to the fever. Administering fluids can help stabilize the blood pressure and reduce the heart rate.
Preventing Shock: Ensuring adequate fluid volume is crucial to prevent hypovolemic shock, which can occur if the body loses too much fluid or blood.

Immediate Actions Taken

The nurse already administered acetaminophen and applied ice packs to help reduce the fever, which are appropriate initial steps. However, continuous monitoring and additional interventions, such as fluid administration, are necessary to stabilize the client’s condition.

Summary

In summary, the nurse should first address the client’s elevated temperature to prevent potential complications from hyperthermia and then administer fluids to stabilize blood pressure and heart rate. This approach prioritizes the most immediate threats to the client’s health and ensures a comprehensive response to the symptoms presented.

A. White coating in the mouth. B. Nausea. C. Myalgia. D. Headache.

Correct Answer is A

Explanation

Choice A rationale
A white coating in the mouth can indicate oral thrush, a common side effect of inhaled corticosteroids like beclomethasone. This requires prompt treatment to prevent further complications.
Choice B rationale
Nausea is a less common side effect of beclomethasone and is not as urgent as oral thrush.
Choice C rationale
Myalgia (muscle pain) is a less common side effect and not as critical as oral thrush.
Choice D rationale
Headache is a common side effect but not as urgent as oral thrush.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a 40-year-old male client in the postanesthesia care unit (PACU) following abdominal surgery. Exhibits Complete the following sentence by using the list of options provided. The nurse should first address the client’s:_________ followed by __________

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

Explanation

A nurse is assessing a client who is taking beclomethasone. Which of the following findings is the priority to report to the provider?

Correct Answer is A

Explanation

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