Which signs would suggest to a nurse that a patient is undergoing a stress response? (Choose all that apply)

Choice A rationale:

While checking intravenous lines for patency and redness is important, it's not the most immediate priority in the post- anesthesia care unit (PACU). Ensuring airway patency and adequate oxygenation takes precedence over IV assessment. Issues with IV lines can usually be addressed quickly if they arise, whereas compromised airway or breathing can rapidly lead to life- threatening complications.

Choice B rationale:

Assessment of nasogastric tubes and bowel sounds is also important, but it's not as urgent as checking the airway and breathing. Bowel sounds may be absent immediately after surgery due to anesthesia and bowel manipulation, and their presence or absence doesn't necessarily indicate an immediate problem. Similarly, nasogastric tubes can be checked and adjusted as needed after ensuring the patient's airway and breathing are stable.

Choice D rationale:

Checking the Foley catheter and surgical fluid intake is essential for monitoring fluid balance and renal function, but it's not a priority over assessing airway, breathing, and circulation (ABCs). Fluid status can be assessed and managed after ensuring the patient's respiratory and circulatory systems are functioning adequately.

Choice C rationale:

Checking the airway, lung sounds, and pulse oximetry is the most critical assessment in the PACU because it ensures that the patient is breathing effectively and has adequate oxygen saturation. This assessment addresses the primary ABCs of patient care:

Airway: The nurse will assess for any obstructions or potential for obstruction, such as swelling, secretions, or the tongue blocking the airway. They will also ensure proper positioning of the head and neck to maintain airway patency.

Breathing: The nurse will listen to lung sounds to evaluate air entry and identify any signs of respiratory distress, such as wheezing, crackles, or decreased breath sounds. They will also monitor respiratory rate and effort.

Circulation: Pulse oximetry measures oxygen saturation in the blood, providing a quick and non-invasive assessment of oxygenation status. It's essential to ensure adequate oxygen delivery to tissues and organs.

By prioritizing the assessment of airway, lung sounds, and pulse oximetry, the nurse can quickly identify and intervene in any respiratory or oxygenation issues, preventing potentially life-threatening complications.

Choice A rationale:

A patient's last bowel movement being 4 days ago does not directly increase their risk of pulmonary embolism (PE). While constipation can be a risk factor for deep vein thrombosis (DVT), which can lead to PE, it is not a significant risk factor on its own.

It's important to assess for other risk factors for DVT, such as immobility, recent surgery, or a history of blood clots, in conjunction with constipation.

Choice C rationale:

A platelet count of 45,000/mm^3 is low (thrombocytopenia), but it does not directly increase the risk of PE.

In fact, a low platelet count can sometimes hinder clot formation. However, it's important to monitor patients with thrombocytopenia for bleeding risks, as they may be more prone to bleeding complications.

Choice D rationale:

While receiving a transfusion of two units of packed red blood cells can increase blood viscosity, which could theoretically slightly increase the risk of PE, it is not a major risk factor.

Patients who receive transfusions are often already at an elevated risk of PE due to other underlying conditions or surgeries. It's essential to assess for other risk factors in these patients.