Answer to Question 1
D
The nurse should notify the physician, as these are abnormal findings. The client's respirations are becoming dangerously low at 8 (normal, 12 to 20 breaths per minute). The client's pulse is low at 54 (expected, 60 to 100 beats per minute), and the optimal blood pressure should be less than 120/80, while the client's blood pressure reading is 110/68 . The additional assessment findings also are not normal and should be reported to the physician.
The nurse should not wait another 30 minutes to retake vital signs. The present readings warrant notifying the physician.
These are abnormal findings. The nurse should not continue with care as planned.
The nurse should first notify the physician. Administering a stimulant would require a physician's order and may not be what the client requires. For example, the client may need a narcotic antagonist rather than a stimulant.
Answer to Question 2
C
Postoperative nausea and vomiting sometimes occur once the patient is at home even if symptoms were not present in the surgery center. Options for therapy include medications. Instructing the patient to call the physician and connecting the patient with the physician can help the patient to obtain relief. Taking deep breaths, drinking ginger ale, and eating crackers are interventions that may be helpful, but this patient needs additional help. Instructing the patient to go to the emergency department is an option with continued nausea and vomiting.
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The general survey includes assessing every patient for signs of distress.
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Using small, circular strokes, exfoliate the client’s neck and back.
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