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

Answer and Explanation

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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Correct Answer is D

Explanation

A. "What brought you to the emergency department today?": This is a general intake question that helps determine the current complaint but does not specifically screen for risk factors or history of cardiomyopathy.
B. "When was the last time you had any nausea or heartburn?": These symptoms may relate to gastrointestinal or cardiac concerns but are nonspecific and not directly used to screen for cardiomyopathy.
C. "Did you have any common childhood diseases?": While relevant in some cases, childhood illnesses are not typically a key factor in identifying familial or inherited forms of cardiomyopathy.
D. "Have you ever had a close family member die unexpectedly?": Sudden cardiac death in a family member can be a red flag for inherited forms of cardiomyopathy, such as hypertrophic cardiomyopathy. This is a critical screening question to assess genetic risk.

A. In a client with an indwelling pacemaker B. In a client who is in elementary school C. In a client who is an older adult D. In a client who is diagnosed with heart failure

Correct Answer is B

Explanation

A. In a client with an indwelling pacemaker: An S3 heart sound is not typically associated with pacemaker use and may suggest underlying heart dysfunction. In adults, it often indicates volume overload or decreased ventricular compliance.
B. In a client who is in elementary school: An S3 sound can be a normal finding in children and young adults due to their compliant ventricles and strong cardiac output. It often disappears with age and is considered "physiologic S3." It is usually soft, low-pitched, and heard best at the apex of the heart.
C. In a client who is an older adult: In older adults, an S3 sound is usually abnormal and may be an early indicator of heart failure or ventricular dysfunction. It suggests poor ventricular compliance and fluid overload.
D. In a client who is diagnosed with heart failure: An S3 sound is commonly heard in heart failure but is not considered normal. It reflects increased filling pressures and reduced ventricular function, making it a key sign of worsening cardiac status.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which common assessment question does the nurse use when admitting all clients that helps to screen for cardiomyopathy?

Correct Answer is D

Explanation

In which client does the nurse consider the presence of an S3 heart sound to be normal?

Correct Answer is B

Explanation

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