A nurse is caring for an older adult client who has just returned from PACU after receiving a spinal anesthetic during knee surgery. For which of the following findings should the nurse notify the provider?
Systolic blood pressure changed from 140 mm Hg to 120 mm Hg
Temperature changed from 37.2° C (99.0° F) to 37.5° C (99.5° F)
Pulse oximetry changed from 98% to 96%
Client reports knee pain, changed from 4/10 to 6/10
The Correct Answer is A
A. A decrease in systolic blood pressure from 140 mm Hg to 120 mm Hg could indicate hypotension. Postoperatively, especially after receiving a spinal anesthetic, hypotension can occur due to vasodilation or decreased sympathetic tone. This change in blood pressure warrants notification of the provider because significant hypotension can lead to inadequate perfusion to vital organs and tissues.
B. A slight increase in temperature from 37.2°C to 37.5°C (99.0°F to 99.5°F) is a mild elevation and may not necessarily require immediate notification unless accompanied by other signs of infection or instability. It could be related to the stress response post-surgery. However, if there are other concerning signs (e.g., increased heart rate, worsening pain), the nurse should reassess and consider further action.
C. A decrease in pulse oximetry from 98% to 96% indicates a mild decrease in oxygen saturation. While this change alone may not be alarming, the nurse should assess the client's respiratory status and potential causes (e.g., positioning, respiratory depression from anesthesia). Oxygen saturation levels below 95% generally require intervention, but 96% is still within a normal range for most clients.
D. An increase in pain from 4/10 to 6/10 indicates worsening pain. Postoperatively, increasing pain may indicate inadequate pain management, worsening condition at the surgical site, or other complications such as hematoma or infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Calling the healthcare provider is a reasonable action, especially when there is a significant change in the patient's condition, such as weight gain and generalized edema. The nurse may need further guidance on adjusting medications or additional interventions.
B. Diuretics are commonly prescribed for patients with heart failure to manage fluid overload. If the patient has not been compliant with taking their diuretic as prescribed, it could contribute to fluid retention and exacerbation of symptoms. Therefore, ensuring medication adherence is important. However, this alone may not address the acute issue of current weight gain and edema.
C. Daily weight monitoring is crucial for patients with heart failure as it can indicate fluid retention early on. Reinforcing the importance of daily weights helps in early detection of changes and facilitates timely intervention. However, in this scenario, the nurse has already noted a significant weight gain and edema since the last visit, so immediate action beyond education is needed.
D. Documenting the findings is essential for maintaining accurate patient records. However, in the context of a patient with heart failure who has shown signs of worsening (weight gain and edema), immediate action to address the worsening condition is necessary.
Correct Answer is D
Explanation
A. An inguinal hernia typically does not directly contribute to an increased risk of falls. It is a condition where tissues, such as part of the intestine, protrude through a weak spot in the abdominal muscles. While it may require caution with certain movements or heavy lifting to prevent exacerbation, it is not typically associated with balance or mobility issues that would increase fall risk.
B. Hyperthyroidism is a condition where the thyroid gland produces excessive thyroid hormone. Symptoms may include nervousness, tremors, rapid heart rate (palpitations), and muscle weakness. While muscle weakness could potentially contribute to an increased fall risk, it's not typically a primary factor unless the weakness is severe or affecting lower extremity strength significantly.
C. Hyperlipidemia refers to elevated levels of lipids (fats) in the blood, such as cholesterol and triglycerides. While it is a risk factor for cardiovascular disease, it does not directly increase the risk of falls.
D. Multiple sclerosis (MS) is a neurological condition that can cause a wide range of symptoms, including muscle weakness, coordination problems, and balance issues. These neurological impairments significantly increase the risk of falls due to impaired mobility and balance control.
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