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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. An advance directive is a legal document that outlines a person's preferences for medical treatment, including end-of-life care. Asking the client if they have a copy of their advance directive is appropriate because it can provide valuable information about their wishes regarding medical interventions. It allows the nurse to review the document to ensure that the client's current wishes align with what is documented in their advance directive.
B. In most cases, a competent adult's healthcare decisions, including decisions to refuse treatment, are legally binding and cannot be overridden by family members. It is important for the nurse to educate the client about their rights and ensure that their wishes are respected. Family members may be involved in discussions and support the client's decisions, but they cannot override a competent adult's wishes regarding their medical care.
C. While it's important to involve family members in discussions about the client's wishes, especially if they are the client's designated healthcare proxy or legally authorized decision-maker, family agreement is not required for the client's decision to refuse life-saving measures. The nurse should primarily focus on the client's expressed wishes and ensure that these wishes are understood and respected.
D. The provider's agreement with the client's decision may be necessary to document and implement the plan of care accordingly, but ultimately, the decision to refuse treatment rests with the competent client. The nurse should facilitate communication between the client and the provider to ensure that the client's wishes are understood and documented appropriately.
Correct Answer is ["A","B","C","D","E"]
Explanation
A. This information highlights the importance of improving hand hygiene practices among healthcare workers. Low compliance rates indicate a need for education, reminders, and possibly changes in the healthcare facility's policies and procedures to encourage better adherence to hand hygiene protocols.
B. Hand hygiene is indeed one of the most critical measures to prevent the transmission of infections in healthcare settings. Proper hand hygiene (either washing with soap and water or using alcohol-based hand rubs) helps reduce the spread of pathogens from person to person, from surfaces to patients, and vice versa.
C. Alcohol-based hand sanitizers (gels, foams, or rubs) are effective and convenient for hand hygiene in healthcare settings. They are recommended by healthcare authorities like the CDC (Centers for Disease Control and Prevention) and WHO (World Health Organization) as they quickly reduce the number of microbes on hands when soap and water are not readily available or practical.
D. This statistic underscores the risk of healthcare-associated infections (HAIs) and the importance of preventive measures such as hand hygiene. Healthcare workers play a crucial role in reducing HAIs through proper hand hygiene practices.
E. Educating clients about hand hygiene is essential for infection prevention, especially in settings where clients can actively participate in their own care (e.g., hospitals, outpatient clinics, long-term care facilities). Clients should be encouraged to practice hand hygiene, particularly after using the restroom, before eating, and after touching surfaces that may harbor pathogens.
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