Author Question: A postoperative nurse is caring for a client whose oxygen saturation dropped from 98 to 95. What ... (Read 105 times)

HCHenry · **on:** Jun 25, 2018

A postoperative nurse is caring for a client whose oxygen saturation dropped from 98 to 95. What action by the nurse is most appropriate?

a. Assess other indicators of oxygenation.
b. Call the Rapid Response Team.
c. Notify the anesthesia provider.
d. Prepare to intubate the client.

Question 2

The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client should the nurse assess first?

a. Client with a blood pressure of 100/50 mm Hg
b. Client with a pulse of 118 beats/min
c. Client with a respiratory rate of 6 breaths/min
d. Client with a temperature of 96 F (35.6 C)

Madisongo23 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: A
If a postoperative client's oxygen saturation (SaO2) drops below 95 (or the client's baseline), the nurse should notify the anesthesia provider. If the SaO2 drops by 10 or more, the nurse should call the Rapid Response Team. Since this is approximately a 3 drop, the nurse should further assess the client. Intubation (if the client is not intubated already) is not warranted.

Answer to Question 2

ANS: C
The respiratory rate is the most critical vital sign for any client who has undergone general anesthesia or moderate sedation, or has received opioid analgesia. This respiratory rate is too low and indicates respiratory depression. The nurse should assess this client first. A blood pressure of 100/50 mm Hg is slightly low and may be within that client's baseline. A pulse of 118 beats/min is slightly fast, which could be due to several causes, including pain and anxiety. A temperature of 96 F is slightly low and the client needs to be warmed. But none of these other vital signs take priority over the respiratory rate.