When caring for a client who has undergone general anesthesia, the nurse's immediate priority interventions would include which of the following? (Select all that apply.)

Question

a. monitoring respirations and blood pressure
b. monitoring for level of consciousness
c. repositioning client frequently
d. encouraging deep breathing
e. providing fluids and missed meal
f. encouraging ambulation
g. keeping the client warm

Answer 1

A, B, C, D, G
Changes in heart rate and blood pressure observed during the recovery phase are indirectly related to anesthesia. Increases in heart rate and blood pressure are related to sympathetic stimulation that occurs with pain, fear, or hypoxia; these normalize when the specific cause(s) are addressed. Warming the client and encouraging deep breathing helps eliminate the anesthetic agents that can cause postoperative shivering. The client may not recall what has happened for some time, and the ability to think clearly takes even longer to return; there may be some residual thinking difficulty that persists for days to weeks after general anesthesia. Most anesthetics act as respiratory depressants; when the rate or depth of respirations decrease, carbon dioxide elimination is impeded and builds up in the blood and the lungs. A nurse should monitor the client's return of motor and sensory function in the blocked area by asking the client to move the body part and to identify if the part is being touched. The client remains at some risk for orthostatic hypotension even after motor and sensory functions have returned. Normal sensation returns gradually as the regional block wears off. The client's body must be checked frequently and protected until normal sensation has completely returned.