A nurse is caring for a client diagnosed with superficial partial-thickness burns over both posterior shoulders.
Which of the following findings should the nurse expect when assessing the client's shoulders?

Choice A rationale

A blood pressure reading of 110/70 mmHg and heart rate of 90 bpm are generally within normal limits or slightly elevated for a post-procedure client. Normal blood pressure is typically below 120/80 mmHg, and a normal heart rate is between 60 and 100 bpm. These parameters alone do not indicate an immediate post-cardiac catheterization complication requiring urgent reporting.

Choice B rationale

Oozing blood from the puncture site, while requiring continued monitoring and potentially manual pressure, is not as immediately critical as active bleeding or signs of hematoma expansion. Small amounts of oozing are sometimes expected due to the invasive nature of the procedure. The nurse should reinforce the dressing and apply direct pressure if needed, but the primary concern is contained bleeding.

Choice C rationale

The client not voiding since returning to recovery warrants assessment for urinary retention, especially if intravenous fluids were administered, but it is not an immediate life-threatening complication post-cardiac catheterization. While monitoring urine output is important for renal function, especially with contrast dye use, it does not typically require immediate reporting to the cardiologist unless accompanied by other signs of renal compromise.

Choice D rationale

Swelling at the insertion site and a cool extremity distal to the puncture are critical findings indicating potential vascular compromise, such as hematoma formation, retroperitoneal bleed, or arterial occlusion. Swelling suggests fluid accumulation, and coolness indicates impaired arterial blood flow, potentially leading to ischemia of the limb. These require immediate intervention to prevent severe limb damage.

Choice A rationale

PEEP, or positive end-expiratory pressure, is applied to increase functional residual capacity and prevent alveolar collapse. It does not increase the shunting effect of oxygen; rather, it aims to reduce physiological shunting by recruiting collapsed alveoli, improving ventilation-perfusion matching, and thus enhancing gas exchange. Increasing shunting would be a detrimental outcome, not a therapeutic goal.

Choice B rationale

PEEP improves oxygenation by maintaining positive pressure in the airways at the end of exhalation, which prevents alveolar collapse and recruits previously collapsed alveoli. This increases the surface area available for gas exchange, allowing for more efficient diffusion of oxygen into the pulmonary capillaries and subsequently into the bloodstream, thus enhancing arterial oxygen saturation.

Choice C rationale

While PEEP is a component of ventilatory support, its primary purpose is not to directly assist with weaning the client off the ventilator. PEEP optimizes lung mechanics and oxygenation, which can indirectly contribute to a client's readiness for weaning by improving their overall respiratory status. However, weaning protocols involve reducing ventilator support, not necessarily increasing PEEP.

Choice D rationale

PEEP actively works to increase, not decrease, the amount of oxygen in the alveoli by preventing their collapse and ensuring they remain open for gas exchange throughout the respiratory cycle. By maintaining alveolar patency, PEEP facilitates a higher residual volume of oxygen in the lungs, improving the driving pressure for oxygen diffusion across the alveolar-capillary membrane.