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 A
Explanation
Rationale
A. Contact precautions are appropriate for MRSA to prevent the transmission of bacteria through direct or indirect contact with the infected area. This includes wearing gloves and gowns when caring for the client and ensuring proper hand hygiene.
B. Droplet precautions are used for pathogens that are spread through respiratory droplets, which is not applicable to MRSA.
C. Protective equipment is typically used for immunocompromised patients to prevent infections, but it is not the standard for MRSA.
D. Airborne precautions are necessary for diseases that spread through airborne particles, which does not include MRSA.
Correct Answer is C
Explanation
Rationale:
A. Compensated metabolic acidosis would show a normal pH with a decrease in HCO3- and a decrease in PaCO2.
B. Compensated respiratory acidosis would show a normal pH with an elevated PaCO2 and a compensatory increase in HCO3-.
C. The low pH indicates acidosis, and the elevated PaCO2 suggests that it is respiratory in origin, with the HCO3- remaining normal, indicating no compensation has occurred yet.
D. Uncompensated metabolic acidosis would present with a low pH, low HCO3-, and normal PaCO2.