Author Question: The postoperative vital signs of an average size adult client are: BP = 110/68 mm Hg, P = 54 ... (Read 176 times)

cartlidgeashley · **on:** Jul 23, 2018

The postoperative vital signs of an average size adult client are: BP = 110/68 mm Hg, P = 54 beats/min, R = 8 breaths/min. The client appears pale, is disoriented, and has minimal urinary output. The nurse should:

1. Retake the vital signs in 30 minutes
2. Continue with care as planned
3. Administer a stimulant
4. Notify the physician

Question 2

A client has just gotten out of bed to go to the bathroom. As the nurse enters the room, the client says, I feel dizzy. The nurse should:

1. Go for help
2. Take the client's blood pressure
3. Assist the client into a sitting position
4. Tell the client to take several deep breaths

Jbrasil · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: 4
The nurse should notify the physician, as these are abnormal findings. The client's respirations are becoming dangerously low at 8 breaths/min (normal 12-20 breaths/min). The client's pulse rate is low at 54 beats/min (expected 60-100 beats/min), and the blood pressure should be =120/80 mm Hg, which it is at 110/68 mm Hg. The additional assessment findings are also 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. Ad-ministering 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

ANS: 3
The nurse's primary concern should be the patient's safety and preventing an accidental fall. If the client just got up from bed and is complaining of dizziness, the client may be experiencing orthostatic hypotension. The nurse should first assist the client to sit down before performing any other assessment. The nurse should not leave the client and go for help. The nurse should assist the client to a sitting position. If help is required, the nurse can then put on the client's call light.
The nurse may take the client's blood pressure after assisting the client to a sitting position to prevent the client from falling. The nurse should first assist the client to sit down to prevent the client from falling accidentally. The nurse may then assess the client. If the nurse finds during the assessment that the client's pulse oximetry is low, the nurse may instruct the client to take deep breaths.