A nurse is caring for an older adult client in the PACU following general anesthesia. Which of the following findings should the nurse report to the provider?
Urine output 120 mL in 4 hr
Systolic blood pressure 12 mm Hg lower than the preoperative level
Audible stridor
Normal sinus rhythm with an occasional premature ventricular contraction
The Correct Answer is C
Rationale:
A. Urine output of 120 mL in 4 hours is within acceptable limits, especially following anesthesia. Normal output can vary, but 30 mL/hr is often used as a guideline.
B. A systolic blood pressure that is only 12 mm Hg lower than preoperative levels may be concerning, but it does not necessarily require immediate reporting unless other symptoms are present.
C. Audible stridor is a sign of airway obstruction or severe respiratory distress and requires immediate medical attention. It should always be reported to the provider.
D. An occasional premature ventricular contraction (PVC) can be common postoperatively and may not necessitate reporting unless accompanied by significant symptoms or changes in hemodynamic status.
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Correct Answer is C
Explanation
Rationale:
A. Concerns about participation in team sports may indicate a desire for improved lung function but do not directly necessitate the use of a high-frequency chest compression vest.
B. Discomfort during nebulizer treatments may warrant alternative therapies, but it is not a direct indication for a high-frequency chest compression vest.
C. A small amount of mucus after percussion therapy suggests inadequate airway clearance, which may prompt the need for more effective techniques, such as the high-frequency chest compression vest, to facilitate mucus clearance and improve lung function.
D. A fever indicates a potential infection and requires further assessment but does not directly suggest the need for a high-frequency chest compression vest.
Correct Answer is B
Explanation
Rationale:
A. Offering flavored gelatin can provide some hydration, but it does not provide sufficient electrolytes necessary for rehydration in gastroenteritis.
B. Initiating oral rehydration therapy for the toddler is essential in treating dehydration caused by infectious gastroenteritis. Oral rehydration solutions contain the right balance of electrolytes and fluids to replenish losses.
C. While chicken broth may provide some fluid and salt, it is not as effective as a specific oral rehydration solution tailored for children with gastroenteritis.
D. The BRAT diet (bananas, rice, applesauce, and toast) is no longer recommended as the primary diet for children with gastroenteritis, as it does not provide adequate nutrition or electrolytes.