On admission of a patient to the postanesthesia care unit (PACU), the blood pressure (BP) is 122/72. Thirty minutes after admission, the BP falls to 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse is most appropriate?
a. Increase the IV fluid rate.
b. Continue to take vital signs every 15 minutes.
c. Administer oxygen therapy at 100% per mask.
d. Notify the anesthesia care provider (ACP) immediately.
ANS: B
A slight drop in postoperative BP with a normal pulse and warm, dry skin indicates normal response to the residual effects of anesthesia and requires only ongoing monitoring. Hypotension with tachycardia and/or cool, clammy skin would suggest hypovolemic or hemorrhagic shock and the need for notification of the ACP, increased fluids, and high-concentration oxygen administration.
You might also like to view...
The nurse received orders to obtain a vaginal culture and start an antibacterial agent. The nurse should:
1. start the drug as ordered and take the culture within 6 hours of drug initiation. 2. obtain the vaginal specimen prior to starting the antibacterial agent. 3. obtain the specimen and add a label stating that the antibacterial agent was started 4 hours prior to collection. 4. delay initiation of the drug until the results have been returned from the laborato-ry.
Which statement is not part of the Ten Commandments of CDS?
a. Speed is everything. b. Fit into the user's workflow. c. Alerting is the most effective approach to CDS. d. Ask for additional information only when you really need it.
Many clients have nutritional needs that are high but whose appetites are poor, such as in clients with advanced COPD. What would be the best nursing action to take to promote maximum intake?
A) Providing pain medications with meals to facilitate digestion B) Scheduling treatments during mealtimes to encourage between meal snacking C) Eating small frequent meals of soft food D) Encouraging the intake of empty-calorie foods and beverages to promote intake
Parents of a school-age child ask the nurse about services provided by school-based clinics. Which statement made by the nurse is accurate with regard to school-based clinic services? Select all that apply
a. Vision, hearing, and growth screening are provided. b. Education about health-related topics is provided to children and parents. c. Minor outpatient surgical procedures can be performed. d. Emergency first aid treatment is provided. e. Casts can be applied to broken bones.