Which assessment finding of a 42-year-old patient who had a ...

[sheilaspns]

Which assessment finding of a 42-year-old patient who had a bilateral adrenalectomy requires the most rapid action by the nurse?
 
  a. The blood glucose is 176 mg/dL.
  b. The lungs have bibasilar crackles.
  c. The blood pressure (BP) is 88/50 mm Hg.
  d. The patient reports 5/10 incisional pain.

Question 2

A 37-year-old patient has just arrived in the postanesthesia recovery unit (PACU) after a thyroidectomy. Which information is most important to communicate to the surgeon?
 
  a. The patient reports 7/10 incisional pain.
  b. The patient has increasing neck swelling.
  c. The patient is sleepy and difficult to arouse.
  d. The patient's cardiac rate is 112 beats/minute.

[braelync]

Answer to Question 1

ANS: C
The decreased BP indicates possible adrenal insufficiency. The nurse should immediately notify the health care provider so that corticosteroid medications can be administered. The nurse should also address the elevated glucose, incisional pain, and crackles with appropriate collaborative or nursing actions, but prevention and treatment of acute adrenal insufficiency is the priority after adrenalectomy.

Answer to Question 2

ANS: B
The neck swelling may lead to respiratory difficulty, and rapid intervention is needed to prevent airway obstruction. The incisional pain should be treated but is not unusual after surgery. A heart rate of 112 is not unusual in a patient who has been hyperthyroid and has just arrived in the PACU from surgery. Sleepiness in the immediate postoperative period is expected.