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","C","D","E"]
Explanation
Choice A rationale:
The client’s temperature has decreased from 37.8°C (100°F) to 37.2°C (99°F). While this is a slight reduction, it indicates a move towards a more normal body temperature. Elevated temperatures can be associated with stress, anxiety, or other underlying conditions. A decrease in temperature suggests that the client’s body is stabilizing and that any potential underlying issues causing the elevated temperature are being managed effectively.
Choice B rationale:
The client’s mood has improved as she appears less anxious and more composed during the physical examination. Anxiety can significantly impact a person’s overall well-being, and a reduction in anxiety levels is a positive indicator of improvement. The client also expresses optimism about her recovery, which is a good sign of mental health improvement.
Choice C rationale:
The client has gained weight, increasing from 53 kg (117 lb) to 55 kg (121 lb). Weight gain in this context is a positive sign, indicating that the client’s body is responding well to treatment and that her nutritional status is improving. Unintentional weight loss can be a symptom of underlying health issues, so reversing this trend is a good indicator of recovery.
Choice D rationale:
The client reports better sleep, which is a significant improvement from her previous insomnia. Sleep is crucial for physical and mental health, and improved sleep patterns can lead to better overall health outcomes. Insomnia can exacerbate anxiety and other health issues, so better sleep is a positive sign.
Choice E rationale:
The client’s heart rate has decreased from 120/min to 95/min. A high heart rate can be a sign of anxiety, stress, or other health issues. A reduction in heart rate indicates that the client’s anxiety levels are decreasing and that her cardiovascular system is stabilizing. This is a positive sign of improvement in her overall health.
Correct Answer is B
Explanation
Choice A rationale
BNP is used to diagnose heart failure, not to monitor gentamicin’s adverse effects.
Choice B rationale
Creatinine levels should be monitored as gentamicin can cause nephrotoxicity, leading to impaired kidney function.
Choice C rationale
Amylase levels are not relevant for detecting gentamicin’s adverse effects.
Choice D rationale
ESR is used to detect inflammation, not specific to gentamicin’s adverse effects.
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