A nurse is obtaining a preoperative medical and surgical history from a client scheduled for a cataract extraction procedure. Which of the following client statements require further investigation by the nurse?

"l stopped taking aspirin last week."

"l did not put my contact lenses in this morning."

"l took my blood pressure meds with a sip of water."

"l had a cough and runny nose a couple days ago."

Answer and Explanation

The Correct Answer is D

A. "I stopped taking aspirin last week.": Stopping aspirin medication prior to surgery is often advised to reduce the risk of bleeding during and after the procedure. The nurse may confirm the timing of discontinuation with the client and verify if any other anticoagulant medications are being taken.

B. "I did not put my contact lenses in this morning.": Removing contact lenses before surgery is a routine precaution to prevent potential corneal abrasions or complications during the procedure. This statement indicates the client is following preoperative instructions.

C. "I took my blood pressure meds with a sip of water.": Taking blood pressure medications with a small amount of water is generally acceptable before surgery. However, the nurse may verify the specific medications the client is taking and their dosing schedule to ensure compliance.

D. "I had a cough and runny nose a couple days ago.": This statement requires further investigation as respiratory symptoms, such as cough and runny nose, may indicate an underlying respiratory infection. Infections can increase the risk of complications during surgery, such as anesthesia-related respiratory issues or postoperative infections. The nurse should assess the severity and duration of the symptoms, inquire about any fever or recent exposure to illnesses, and consider notifying the surgical team for further evaluation and decision-making regarding the client's surgical readiness.

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Correct Answer is D

Explanation

A. The client develops bradycardia and bradypnea: Bradycardia (slow heart rate) and bradypnea (slow breathing rate) may indicate a slowing down of bodily functions but are not typical manifestations of postoperative shock. In postoperative shock, the body's compensatory mechanisms often lead to tachycardia (rapid heart rate) and tachypnea (rapid breathing rate) as the body tries to maintain perfusion.

B. The client has metabolic alkalosis and warm extremities: Metabolic alkalosis and warm extremities are not typically associated with postoperative shock. In shock, metabolic acidosis is more common due to tissue hypoperfusion, and extremities may become cool due to peripheral vasoconstriction as the body attempts to shunt blood to vital organs.

C. The client has hypertension and anuria: Hypertension (high blood pressure) and anuria (lack of urine output) are not indicative of postoperative shock. In shock, blood pressure typically decreases (hypotension), and oliguria or anuria may occur due to decreased renal perfusion.

D. The client has hypotension and is confused: This is the correct answer. Hypotension (low blood pressure) is a hallmark sign of shock, indicating inadequate tissue perfusion. Confusion may occur due to cerebral hypoperfusion and inadequate oxygen delivery to the brain. Confusion is a late sign of shock and indicates severe compromise of organ perfusion.

A. A decrease in systolic blood pressure greater than 10 mm Hg during inspiration B. A decrease in heart rate greater than 10/min when lying down C. An increase in diastolic blood pressure greater than 10 mm Hg during inspiration D. An increase in heart rate greater than 20/min when standing

Correct Answer is A

Explanation

A. A decrease in systolic blood pressure greater than 10 mm Hg during inspiration: Pulsus paradoxus is an exaggerated decrease in systolic blood pressure during inspiration. Normally, there is a slight decrease in systolic blood pressure during inspiration due to increased intrathoracic pressure and decreased venous return to the heart. However, in conditions such as cardiac tamponade or severe asthma exacerbations, the decrease in systolic blood pressure during inspiration is more pronounced (>10 mm Hg), indicating impaired cardiac output and decreased left ventricular filling during inspiration.

B. A decrease in heart rate greater than 10/min when lying down: This finding is not indicative of pulsus paradoxus. Pulsus paradoxus primarily refers to changes in systolic blood pressure during inspiration rather than alterations in heart rate when lying down.

C. An increase in diastolic blood pressure greater than 10 mm Hg during inspiration: This finding is not indicative of pulsus paradoxus. Pulsus paradoxus is characterized by an exaggerated decrease in systolic blood pressure during inspiration, not changes in diastolic blood pressure.

D. An increase in heart rate greater than 20/min when standing: This finding is not indicative of pulsus paradoxus. Pulsus paradoxus primarily refers to changes in systolic blood pressure during inspiration rather than alterations in heart rate when standing.

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A nurse is obtaining a preoperative medical and surgical history from a client scheduled for a cataract extraction procedure. Which of the following client statements require further investigation by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care for a postoperative client. Which of the following manifestations should the nurse identify as indicating the development of postoperative shock?

Correct Answer is D

Explanation

A nurse is assessing a client suspected of having cardiac tamponade. Which of the following findings indicates the presence of pulsus paradoxus?

Correct Answer is A

Explanation

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