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 B

Explanation

B. Pallor of the toes indicates compromised blood flow and is the earliest sign of circulatory impairment due to tightness of the cast.

A. Inability to move toes may be a sign of tightness in the cast, but it is not the first finding to be expected if the cast is too tight.

C. Change in temperature of the toes may be a sign of impaired circulation, but it is not the earliest finding to be expected.

D. Edema of the toes may occur as a result of compromised circulation, but it is not the first finding to be expected if the cast is too tight.

A. A plaster cast requires expensive equipment for application. B. A synthetic case immobilizes bone fractures more effectively. C. A synthetic cast is weighs less. D. Drying time is prolonged with a synthetic cast.

Correct Answer is C

Explanation

C. Synthetic casts are indeed lighter in weight compared to plaster casts. This lighter weight can improve patient comfort and mobility during the healing process.

A. Plaster casts typically do not require expensive equipment for application. The materials needed for applying a plaster cast are relatively inexpensive and readily available in most healthcare settings.

B. Both the synthetic and plaster casts have relatively equal efficacy in fracture immobilization.

D. Synthetic casts typically have a shorter drying time compared to plaster casts. They may dry within 10 to 30 minutes, whereas plaster casts can take longer, often several hours, to fully dry and harden.

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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

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Correct Answer is C

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