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 A

Explanation

Choice A rationale
Naloxone is an opioid antagonist that rapidly reverses the effects of opioid overdose, including respiratory depression. It binds to opioid receptors and displaces the opioid molecules, reversing their effects.
Choice B rationale
Bisacodyl is a stimulant laxative used to treat constipation. It does not have any effect on opioid-induced respiratory depression.
Choice C rationale
Flumazenil is a benzodiazepine antagonist used to reverse the effects of benzodiazepines, not opioids. It is not effective in treating opioid-induced respiratory depression.
Choice D rationale
Pentazocine is an opioid agonist-antagonist used for pain relief. It does not reverse opioid-induced respiratory depression and can potentially worsen the condition.

A. Sitagliptin. B. Glipizide. C. Metoprolol. D. Losartan.

Correct Answer is D

Explanation

Choice A rationale
Sitagliptin is a DPP-4 inhibitor used to manage blood sugar levels in type 2 diabetes but does not specifically slow the progression of nephropathy.
Choice B rationale
Glipizide is a sulfonylurea that helps control blood sugar levels but does not have a direct effect on slowing nephropathy progression.
Choice C rationale
Metoprolol is a beta-blocker used to manage hypertension but does not specifically target nephropathy progression.
Choice D rationale
Losartan is an angiotensin II receptor blocker (ARB) that helps manage hypertension and has been shown to slow the progression of nephropathy in patients with type 2 diabetes.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is experiencing respiratory depression after taking an excessive dose of oxycodone. Which of the following medications should the nurse expect to administer?

Correct Answer is A

Explanation

A nurse is caring for a client who has hypertension and nephropathy due to type 2 diabetes mellitus. The nurse should expect to administer which of the following medications to slow the progression of the nephropathy?

Correct Answer is D

Explanation

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 providing teaching to a client who has type 2 diabetes mellitus and is starting to take immediate-release exenatide. Which of the following client statements indicates an understanding of the teaching?

A nurse is caring for a client who refuses a prescribed influenza immunization. Which of the following actions should the nurse take first?

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A nurse is providing teaching to a client who has a new prescription for allopurinol to treat gout. Which of the following instructions should the nurse include in the teaching?

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