The postoperative recovery room nurse determines that a client in ...

[rachel9]

The postoperative recovery room nurse determines that a client in the postoperative phase of care can be transitioned to Phase II of recovery.
 
  The client is able to take deep breaths and cough, is using oxygen to maintain a saturation of greater than 90, is fully awake, has a systolic blood pressure that is 130 mmHg now but the preoperative systolic blood pressure was 100 mmHg, and is able to move all four extremities independently. Using the following scale, this client's Aldrete score is ________.
 
  The Aldrete score
 
  Respiration
  2 = Able to take deep breath and cough
  1 = Dyspnea/shallow breathing
  0 = Apnea
 
  O2 Saturation
  2 = Maintains > 92 on room air
  1 = Needs O2 inhalation to maintain O2 saturation > 90
  0 = Saturation < 90 even with supplemental oxygen
 
  Consciousness
  2 = Fully awake
  1 = Arousable on calling
  0 = Not responding
 
  Circulation
  2 = BP+ 20 mmHg preop
  1 = BP+ 20-50 mmHg preop
  0 = BP+ 50 mmHg preop
 
  Activity
  2 = Able to move 4 extremities
  1 = Able to move 2 extremities
  0 = Able to move 0 extremities

Question 2

The postoperative nurse is planning care for a client recovering from major thoracic surgery. Which nursing diagnoses should the nurse select to plan for this client's immediate care needs?
 
  Select all that apply.
  A) Risk for Impaired Gas Exchange
  B) Risk for Decreased Cardiac Output
  C) Risk for Ineffective Airway Clearance
  D) Risk for Imbalanced Nutrition: Less than Body Requirements
  E) Risk for Imbalanced Fluid Volume

[itsakadoozi]

Answer to Question 1

Answer: 8

The Aldrete system is designed to assess a client's transition from Phase I recovery to Phase II recovery, from discontinuation of anesthesia until return of protective reflexes and motor function. The criteria of respirations, oxygen saturation, consciousness, circulation, and activity are scored. The maximum score is 10. Clients who score > 8 are considered fit for transition to Phase II recovery.

Answer to Question 2

Answer: A, B, E

Nursing diagnoses appropriate for the immediate postoperative phase include the Risk for Impaired Gas Exchange because of anesthesia medications and hypothermia, the Risk for Decreased Cardiac Output because of anesthesia, and the Risk for Imbalanced Fluid Volume because of blood loss and nothing by mouth status. The Risk for Ineffective Airway Clearance might be appropriate later as the client recovers from surgery. There is no Risk for Imbalanced Nutrition: Less than Body Requirements during the immediate postoperative phase.

[rachel9]

Excellent

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TYSM