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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Catheter irrigation involves flushing the catheter with a sterile solution to clear any obstruction within the tubing or catheter itself. It can help in cases where there might be clots obstructing urine flow. However, irrigating the catheter is an intervention that requires proper assessment and order from the healthcare provider.
B. This option suggests adjusting the rate of the bladder irrigant, which typically refers to the irrigation solution used during the TURP procedure to maintain catheter patency and prevent clot formation. However, this action requires assessment of the situation and potential orders from the provider.
C. Notifying the provider is often the first action the nurse should take when encountering a significant change in the client's condition or a potential complication, such as a blocked catheter. The provider needs to be informed so they can assess the situation, provide further orders, and decide on the appropriate course of action to manage the urinary retention effectively.
D. Checking the tubing for kinks or other external obstructions is a prudent initial action. Kinks or twists in the catheter tubing can prevent urine from draining properly. If a kink is identified, it can be corrected immediately, allowing urine to flow freely again.

A. The client is experiencing episodes of confusion. B. The client developed a tolerance to the medication. C. The client has become addicted to the medication. D. The client not been taking the medication properly.

Correct Answer is B

Explanation

A. Episodes of confusion could indicate various issues, such as metabolic disturbances, disease progression affecting the central nervous system, or medication side effects. However, confusion alone would not typically lead to an increase in morphine dosage. Therefore, this is not a likely explanation for why the client needed more morphine for pain relief.
B. Tolerance occurs when the body adapts to the effects of a medication over time, requiring higher doses to achieve the same therapeutic effect. This is a common phenomenon with opioids like morphine when used long-term for pain management. If the client's pain relief diminished despite increasing the dose, tolerance to morphine could indeed be the reason why higher doses were needed.
C. Addiction is a psychological and physiological dependence on a substance characterized by compulsive drug-seeking behavior and use despite harmful consequences. Addiction is not typically the reason why a client with terminal cancer would require an increased dose of morphine for pain relief. In this context, the focus is on managing pain rather than addiction.
D. If the client has not been adhering to the prescribed dosing schedule or has missed doses, it could result in inadequate pain control. This might necessitate an increase in morphine dosage to achieve adequate pain relief. However, this scenario would require further assessment to confirm.

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A nurse is caring for a 20-year-old client who has a fever and reports severe headache.

Exhibits

A nurse is preparing the client for a lumbar puncture. Which of the following actions should the nurse take? Select all that apply.

View Question and Answer

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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?

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Explanation

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