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.
Complete the following sentence by using the lists of options:
The nurse should first address the client's
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Methimazole does not typically cause constipation. It is used to treat hyperthyroidism by inhibiting the production of thyroid hormones.
Choice B rationale
A sore throat can be a sign of agranulocytosis, a serious side effect of methimazole that involves a dangerously low white blood cell count. Patients are advised to contact their provider if they experience a sore throat.
Choice C rationale
While monitoring weight is important for patients with hyperthyroidism, it is not a specific instruction related to methimazole use.
Choice D rationale
Methimazole should be taken regularly as prescribed, not on an as-needed basis.
Correct Answer is D
Explanation
Choice A rationale
Taking ibandronate immediately after a meal is incorrect because food and beverages can significantly decrease the absorption of ibandronate. It should be taken on an empty stomach at least 60 minutes before any food or drink.
Choice B rationale
Drinking 8 ounces of milk when taking ibandronate is incorrect because calcium in milk can interfere with the absorption of the medication. It should be taken with plain water only.
Choice C rationale
Taking ibandronate before bedtime is incorrect because the patient needs to remain upright for at least 60 minutes after taking the medication to prevent esophageal irritation.
Choice D rationale
Taking one tablet of ibandronate on the same date each month is correct. This ensures consistent dosing and helps maintain the medication’s effectiveness.
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