A nurse is caring for a client in the postanesthesia care unit (PACU). Exhibits Complete the following sentence by using the lists of options. The nurse should first address the client's dropdown, followed by the client’sdropdown and dropdown.
Explanation & Rationale
Oxygen saturation: The client’s oxygen saturation has dropped to 86%, which is critical. Adequate oxygenation must be restored immediately to prevent hypoxia, especially in the postanesthesia phase. Addressing oxygen first is the priority to ensure client’s stability. Muscle rigidity: Muscle rigidity is a hallmark sign of malignant hyperthermia, a potentially life-threatening complication that should be addressed promptly by administering dantrolene, as it directly contributes to the rise in temperature and worsening clinical condition. Temperature: The core body temperature of 40.2° C (104.4° F) is dangerously high and a hallmark of malignant hyperthermia. Uncontrolled hyperthermia leads to rapid cellular damage, coagulopathies, and multi-organ failure. Aggressive cooling measures must be initiated. Rationale for Incorrect Choices: Blood pressure: The client’s blood pressure is on the low side of normal but does not indicate a life-threatening crisis at this moment compared to the other issues. Hypotension can be managed once oxygenation and the underlying cause of malignant hyperthermia are addressed. Respiratory rate: The respiratory rate is elevated, but it is compensatory for the decreased oxygen levels. Once oxygen saturation is addressed, the respiratory rate should improve. This is secondary to oxygenation and muscle rigidity. Heart rate: The elevated heart rate is likely a result of the client's body trying to compensate for hypoxia and the stress of malignant hyperthermia. Correcting oxygenation and muscle rigidity will likely reduce the heart rate, making it a lower priority than those two issues.