The nurse is caring for a client during an intraoperative procedure. When assessing vital signs, which result indicates a need to alert the anesthesiologist immediately?
Blood pressure of 104/62 mm Hg
Respiratory rate of 18 breaths/min
Temperature of 102.5 °F (39 °C)
Pulse rate of 110 beats/min
The Correct Answer is C
A. Blood pressure of 104/62 mm Hg: This is a mild drop that may be expected under anesthesia and is usually well tolerated. It does not typically require urgent intervention.
B. Respiratory rate of 18 breaths/min: A normal respiratory rate during an intraoperative procedure (especially with ventilatory support) is not alarming and does not require immediate action.
C. Temperature of 102.5 °F (39 °C): A rapid temperature rise may indicate malignant hyperthermia, a life-threatening reaction to anesthesia. The anesthesiologist must be alerted immediately to initiate emergency treatment.
D. Pulse rate of 110 beats/min: This is mildly elevated and may occur due to pain, anxiety, or medications. It should be monitored but is not as urgent as a rising temperature during surgery.
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Related Questions
Correct Answer is B
Explanation
A. Monitor heart rhythm: While cardiac monitoring is important, it doesn’t directly assess airway status or ventilation. Respiratory compromise must be identified through airway-focused assessments.
B. Auscultate lung sounds: Hourly lung auscultation helps detect early signs of airway obstruction, stridor, or atelectasis. It’s the most direct way to monitor for post-extubation respiratory issues.
C. Assess capillary refill: Capillary refill assesses peripheral perfusion but gives little information about airway patency or breathing effectiveness after extubation.
D. Obtain vital signs: Vital signs are useful but may not change until respiratory compromise becomes severe. Lung assessment provides earlier clues of deterioration.
Correct Answer is D
Explanation
A. Administer the medications and then notify the health care provider: Administering digoxin with a heart rate below 60 bpm can worsen bradycardia and lead to complications like heart block. The drug should be withheld first.
B. Administer atropine to speed the heart rate and then administer the digoxin: Atropine is not given prophylactically without a provider's order. It is used in emergency settings for symptomatic bradycardia, not as a pre-treatment for digoxin.
C. Administer the medication and inform the charge nurse about the rate: This does not follow safe medication guidelines. Administering digoxin without addressing the low heart rate may lead to serious adverse effects.
D. Withhold the medication and notify the health care provider of the heart rate: This is the safest and most appropriate action. Digoxin should be withheld if the apical pulse is below 60 bpm, and the provider must be informed for further evaluation.
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