Author Question: A patient's blood pressure in the postanesthesia care unit (PACU) has dropped from an admission ... (Read 108 times)

Yolanda · **on:** Jun 25, 2018

A patient's blood pressure in the postanesthesia care unit (PACU) has dropped from an admission blood pressure of 140/86 to 102/60 with a pulse change of 70 to 96. SpO2 is 92 on 3 L of oxygen.

In which order should the nurse take these actions? (Put a comma and a space between each answer choice A, B, C, D.)
a. Increase the IV infusion rate.
b. Assess the patient's dressing.
c. Increase the oxygen flow rate.
d. Check the patient's temperature.

Question 2

While ambulating in the room, a patient complains of feeling dizzy. In what order will the nurse accomplish the following activities? (Put a comma and a space between each answer choice A, B, C, D.)

a. Have the patient sit down in a chair.
b. Give the patient something to drink.
c. Take the patient's blood pressure (BP).
d. Notify the patient's health care provider.

Jsherida · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS:
A, C, B, D
The first nursing action should be to increase the IV infusion rate. Because the most common cause of hypotension is volume loss, the IV rate should be increased. The next action should be to increase the oxygen flow rate to maximize oxygenation of hypoperfused organs. Because hemorrhage is a common cause of postoperative volume loss, the nurse should check the dressing. Finally, the patient's temperature should be assessed to determine the effects of vasodilation caused by rewarming.

Answer to Question 2

ANS:
A, C, B, D
The first priority for the patient with syncope is to prevent a fall, so the patient should be assisted to a chair. Assessment of the BP will determine whether the dizziness is due to orthostatic hypotension, which occurs because of hypovolemia. Increasing the fluid intake will help prevent orthostatic dizziness. Because this is a common postoperative problem that is usually resolved through nursing measures such as increasing fluid intake and making position changes more slowly, there is no urgent need to notify the health care provider.