A patient is admitted to the postanesthesia care unit (PACU) with a blood pressure (BP) 122/72 mm Hg. Thirty minutes after admission, the BP is 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse is most appropriate?

Continue to take vital signs every 15 minutes.

Notify the anesthesia care provider (ACP).

Increase the postoperative IV fluid rate.

Administer oxygen therapy at 100% per mask.

Answer and Explanation

The Correct Answer is A

A. Vital sign monitoring every 15 minutes is a standard practice in the postanesthesia care unit (PACU) to closely monitor the patient's hemodynamic status and response to anesthesia. However, in this scenario, the patient's blood pressure (BP) and other vital signs are within an acceptable range, and there are no signs of instability.

B. The patient's vital signs, including BP, pulse rate, and skin condition, are within normal limits. There are no indications of hemodynamic instability or adverse events.

C. There is no indication to increase the postoperative intravenous (IV) fluid rate based solely on the patient's stable vital signs and absence of signs of dehydration or hypovolemia. Increasing IV fluids without clinical indication may lead to fluid overload and potential complications.

D. The patient's oxygen saturation level is not provided in the scenario, and there are no signs or symptoms of respiratory distress or hypoxemia. Therefore, administering oxygen therapy at 100% per mask is not warranted at this time.

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Correct Answer is ["A","D","E"]

Explanation

A. Smoking has been associated with an increased risk of developing osteoarthritis, particularly in the knees and hips. Smoking may contribute to inflammation and oxidative stress, which can exacerbate joint damage.

D. Aging is a significant risk factor for osteoarthritis. As individuals age, the cartilage in their joints may naturally deteriorate over time, leading to the development of osteoarthritis.

E. Obesity is a well-established risk factor for osteoarthritis, particularly in weight-bearing joints such as the knees and hips. Excess body weight places increased stress on the joints, leading to accelerated wear and tear of the joint cartilage.

B. Bacteria are not typically associated with the development of osteoarthritis. Osteoarthritis is primarily a non-inflammatory condition related to wear and tear on the joints rather than an infectious process.

C. Diuretics are medications used to treat conditions such as hypertension and edema by increasing urine output. There is no direct evidence linking diuretic use to the development of osteoarthritis.

A. Tympanic temperature 99.2° F (37.3° C) B. Fine crackles audible at both lung bases C. 200 mL sanguineous fluid in the wound drain D. Redness and swelling along the suture line

Correct Answer is C

Explanation

C. Excessive sanguineous fluid in the drain could indicate active bleeding or a hematoma formation, which are significant concerns after surgery. It should be reported to allow for appropriate intervention to prevent shock

A. A slight elevation in temperature can be expected in the immediate postoperative period due to the body's response to surgery (surgical stress response).

B. Fine crackles indicate the presence of fluid in the lungs, which could suggest complications such as pulmonary edema or atelectasis. While this finding warrants monitoring and intervention, it may not be the most critical issue to report to the surgeon in this context.

D. Redness and swelling along the suture line can indicate inflammation or infection at the surgical site. This is a normal response of the tissues to trauma such as surgery.

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A patient is admitted to the postanesthesia care unit (PACU) with a blood pressure (BP) 122/72 mm Hg. Thirty minutes after admission, the BP is 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse is most appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client about risk factors for osteoarthritis. Which of the following factors should the nurse include in the teaching? (Select all that apply.)

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