Difficulty: Medium
Average Score: 91%
Simulated
Passage / Scenario
Vital SignsNurses' Notes
Physical Examination Results
1220
Temperature: 40.2┬░ C (104.4┬░ F)
Respiratory rate: 24/min
Heart rate: 125/min
Blood pressure: 90/60 mm Hg
Oxygen saturation: 86% on 2 L oxygen via nasal cannula
A nurse is caring for a 35-year-old male client in the postanesthesia care unit (PACU) following a laparoscopic appendectomy. The client is drowsy and responsive to voice. As part of the assessment, the nurse must monitor the clientÔÇÖs status and respond to changes.
Exhibits
Complete the following sentence by using the lists of options:
The nurse should first address the client's Oxygen saturationRespiratory rateBlood pressureMuscle rigidity, followed by the clientÔÇÖs Heart rateTemperatureNausea and vomitingBlood pressure.
Complete the following sentence by using the lists of options: The nurse should first address the client'sOxygen saturationRespiratory rateBlood pressureMuscle rigidity, followed by the client'sHeart rateTemperatureNausea and vomitingBlood pressure.
Correct answer
A,C
Rationale
To determine the correct answer, consider the priority in assessing a client's condition. Oxygen saturation and blood pressure are vital signs that provide immediate information about the client's respiratory and circulatory status, which are crucial for identifying potential life-threatening conditions. Therefore, the nurse should first address the client's Oxygen saturation and Blood pressure (C) to ensure adequate oxygenation and perfusion. Muscle rigidity (D), Heart rate (E), Temperature (F), and Nausea and vomiting (G) are important assessments but are not as immediate as oxygen saturation and blood pressure in determining the client's overall condition. Therefore, they can be addressed after Oxygen saturation and Blood pressure. Respiratory rate (B) is also important but is typically assessed along with oxygen saturation.