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. This instruction is important for safely disposing of needles after use. Safety devices, such as needle safety shields or retractable needles, should be activated immediately after use to prevent accidental needlestick injuries during disposal. Engaging the safety device helps enclose the needle and reduce the risk of subsequent handling injuries.
B. Large-bore needles, which include needles used for procedures such as blood draws or injections, should be disposed of into puncture-resistant sharps containers, not waterproof wastebaskets. Sharps
containers are specifically designed to safely collect needles and prevent accidental needlestick injuries. Using waterproof wastebaskets does not provide adequate protection and increases the risk of injuries.
C. Bending needles, even those without safety devices, is not recommended. Manipulating needles can increase the risk of needlestick injuries. It is safer to dispose of needles intact into sharps containers designed for safe disposal. Sharps containers are puncture-resistant and prevent accidental exposures to used needles.
D. Sharps containers should not be used until they are completely full. They should be replaced and disposed of according to healthcare facility protocols and regulatory guidelines. Overfilling sharps containers increases the risk of needlestick injuries during disposal and handling. It is essential to follow facility policies for timely replacement and disposal of sharps containers to maintain a safe environment.
Correct Answer is ["A","B","C","D"]
Explanation
Correct choices are:
Hoarse voice
A hoarse voice can indicate injury or irritation to the recurrent laryngeal nerve, which is a common complication following thyroid surgery. This nerve is located near the thyroid gland and can be affected during thyroidectomy, leading to vocal cord dysfunction. It's important to report this change in voice to the provider for further evaluation and management.
Tingling around the mouth
Tingling around the mouth can be a sign of hypocalcemia, which is a potential complication after thyroidectomy due to inadvertent damage or removal of the parathyroid glands. These glands regulate calcium levels in the body. Hypocalcemia can present with symptoms such as tingling, numbness, and muscle spasms. Prompt reporting is necessary so that calcium levels can be assessed and appropriate treatment initiated if needed.
Temperature increase from 37.5°C (99.5°F) to 38.6°C (101.5°F) within 1 hour
A rapid increase in temperature postoperatively may indicate infection, such as surgical site infection or systemic infection. This is particularly concerning given the recent surgical procedure. Reporting this change in temperature promptly allows the provider to assess for signs of infection, order appropriate diagnostic tests (such as blood cultures or wound cultures), and initiate timely treatment.
Moderate serosanguinous drainage noted on neck dressing
Serosanguinous drainage (clear to slightly bloody fluid) on the neck dressing is expected post- thyroidectomy, but the amount and nature of drainage should be assessed regularly for any signs of excessive bleeding or infection. Reporting moderate drainage ensures that the provider can assess for complications, such as hematoma formation or wound infection, and intervene as necessary.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.