✔ Encourage the client to perform deep breathing exercises.

◆ Following procedural sedation, clients commonly experience hypoventilation and shallow breathing, increasing the risk for atelectasis and impaired gas exchange.

◆ The client's oxygen saturation is progressively declining (94% → 92% → 90%) despite increasing oxygen flow, indicating that supplemental oxygen alone is not adequately correcting the underlying problem.

◆ Deep breathing exercises promote alveolar expansion, reopen collapsed alveoli, and improve ventilation-perfusion (V/Q) matching, leading to more effective oxygen exchange.

◆ Because the client is arousable and oriented to person and place, they are able to follow simple commands and participate in deep breathing exercises.

◆ Encouraging deep breathing is a first-line nursing intervention that helps prevent postoperative pulmonary complications such as atelectasis and pneumonia.

◆ Improving lung expansion may increase oxygen saturation without the need for more advanced oxygen delivery devices.

◆ This intervention is noninvasive, safe, and evidence-based, making it appropriate before escalating respiratory support.

◆ Early respiratory interventions are essential in the PACU because respiratory depression is one of the most common complications following sedation.

✔ Examine the client's nail beds.

◆ Declining oxygen saturation requires not only intervention but also a thorough clinical assessment to determine the severity of hypoxemia.

◆ Examining the nail beds for cyanosis helps identify whether inadequate oxygenation is affecting peripheral tissues.

◆ Cyanosis is a late but important clinical sign of significant hypoxemia and should prompt immediate reassessment and intervention.

◆ Physical assessment findings should always be correlated with pulse oximetry readings, as factors such as poor circulation, movement, or equipment issues can affect monitor accuracy.

◆ Assessing the nail beds also provides information about peripheral perfusion, which is important when evaluating oxygen delivery to tissues.

◆ Continuous assessment allows the nurse to determine whether the client's oxygenation is improving or deteriorating despite increasing oxygen therapy.

◆ Recognizing early signs of worsening hypoxemia supports timely interventions and helps prevent respiratory compromise.

◆ Combining objective data (SpO₂) with physical findings reflects comprehensive nursing assessment and promotes safe postoperative care.

❌Place the client in the supine position.

◆ The supine position can reduce lung expansion and worsen ventilation.

◆ A semi-Fowler's or high-Fowler's position is preferred to promote optimal oxygenation.

❌Add a humidifier to the oxygen device.

◆ Oxygen delivered via a nasal cannula at 2–5 L/min does not routinely require humidification.

◆ Adding a humidifier will not correct the client's declining oxygen saturation.

❌Prepare to administer oxygen via Venturi face mask.

◆ A Venturi mask is primarily used when a precise oxygen concentration is required, such as for clients with COPD.

◆ The current provider prescription specifies oxygen via nasal cannula (2–5 L/min), making a Venturi mask unnecessary at this stage.

◆ Assistive personnel (AP) can perform routine, noninvasive tasks for stable clients, including obtaining vital signs.

◆ Measuring a rectal temperature does not require nursing assessment, clinical judgment, or interpretation during the procedure itself.

◆ The RN remains responsible for evaluating the results and determining whether additional interventions are needed.

◆ Delegating routine data collection allows the RN to focus on higher-level nursing responsibilities, such as assessment and client education.

◆ Safe delegation requires assigning tasks that are predictable, have established procedures, and fall within the AP's scope of practice.

❌Dressing change for a stage 3 pressure injury

◆ A stage 3 pressure injury requires nursing assessment of wound healing, tissue appearance, drainage, and signs of infection.

◆ Dressing changes for complex wounds must be performed by the RN or licensed practical/vocational nurse (LPN/LVN), depending on facility policy.

❌Verifying placement of an NG tube

◆ Verification of NG tube placement requires clinical judgment to ensure safe medication administration or enteral feeding.

◆ This responsibility cannot be delegated to assistive personnel.

❌Insertion of a peripheral IV

◆ Peripheral IV insertion is a sterile invasive procedure that requires specialized training, assessment, and ongoing monitoring.

◆ It is outside the scope of practice of assistive personnel.

◆ An esophagogastroduodenoscopy (EGD) is an invasive diagnostic procedure that requires informed consent before it is performed.

◆ The nurse is responsible for verifying that informed consent has been obtained and documented before administering preprocedural medications or transporting the client.

◆ The health care provider explains the purpose, risks, benefits, and alternatives of the procedure, while the nurse ensures the client has signed the consent voluntarily.

◆ Confirming informed consent protects the client's legal and ethical right to make informed decisions about their care.

◆ This is a priority nursing responsibility before any invasive procedure.

❌Inform the client the procedure will take 60 min.

◆ The duration of an EGD is typically much shorter, usually 15 to 30 minutes, although recovery from sedation may take longer.

◆ Providing inaccurate information may increase client anxiety and create unrealistic expectations.

❌Administer an oral contrast solution.

◆ Oral contrast is not required for an EGD.

◆ The procedure involves direct visualization of the upper gastrointestinal tract using an endoscope, not radiographic imaging.

❌Ensure that the client's bladder is full.

◆ A full bladder is not necessary for an EGD.

◆ Clients are instead instructed to remain NPO for 6 to 8 hours before the procedure to reduce the risk of aspiration during sedation.

Formula:

(Desired Dose ÷ Dose on Hand) × Volume on Hand

Substitute:

(3.75 mg ÷ 5 mg) × 1 mL

= 0.75 × 1 mL

= 0.75 mL

◆ Gout is an inflammatory arthritis caused by the deposition of monosodium urate crystals within joints due to hyperuricemia.

◆ The client presents with the classic manifestations of acute gout: sudden onset of severe pain, redness, warmth, swelling, and tenderness of the right great toe (podagra).

◆ The statement, "It hurts so bad I can't even sleep with a sheet on top," is highly characteristic of gout because even light pressure causes intense pain due to acute joint inflammation.

◆ A major clue is that the client's symptoms developed 2 weeks after starting hydrochlorothiazide, a thiazide diuretic known to decrease renal excretion of uric acid, increasing the risk for hyperuricemia and gout attacks.

◆ Additional risk factors include chronic kidney disease, which reduces uric acid clearance, obesity, and regular alcohol consumption (2–3 glasses of red wine daily), all of which contribute to elevated uric acid levels.

◆ The absence of trauma makes a fracture less likely, while the lack of fever or systemic illness decreases the likelihood of septic arthritis. There is also no vesicular rash suggestive of shingles.

◆ Recognizing medication-induced gout is an important NCLEX concept, especially in clients recently started on thiazide or loop diuretics.

Actions to Take

✔ Anticipate a prescription for colchicine

◆ Colchicine is commonly prescribed for acute gout attacks because it reduces the inflammatory response triggered by urate crystal deposition rather than lowering uric acid immediately.

◆ It is most effective when initiated within the first 24–36 hours after symptom onset.

◆ The medication helps relieve joint pain, swelling, redness, and tenderness, improving the client's comfort during the acute phase.

◆ Clients with chronic kidney disease require careful monitoring because colchicine is cleared by the kidneys and dosage adjustments may be necessary.

◆ Early treatment shortens the duration and severity of an acute gout flare.

✔ Recommend a low purine diet

◆ Purines are metabolized into uric acid; therefore, reducing dietary purines helps lower uric acid production.

◆ The nurse should encourage limiting foods such as organ meats, red meat, shellfish, sardines, anchovies, and beer/alcohol, which are high in purines.

◆ Adequate hydration should also be encouraged to promote renal excretion of uric acid.

◆ Dietary modification complements medication therapy and helps reduce recurrent gout attacks.

◆ Lifestyle changes are especially important in clients with obesity, hypertension, and chronic kidney disease, as these conditions increase the risk of recurrent gout.

Parameter:

✔ Uric acid level

◆ Serum uric acid helps evaluate the client's underlying hyperuricemia and long-term disease management.

◆ Although levels may occasionally be normal during an acute flare, they remain an important marker for monitoring treatment effectiveness over time.

◆ Persistent elevation increases the risk of recurrent gout attacks, tophi formation, and kidney stones.

◆ Monitoring uric acid guides decisions regarding long-term urate-lowering therapy after the acute attack resolves.

✔Pain level

◆ Pain assessment is the most direct indicator of improvement during an acute gout attack.

◆ The nurse should monitor pain regularly using a standardized pain scale before and after treatment.

◆ Decreasing pain indicates that anti-inflammatory therapy is effective and joint inflammation is resolving.

◆ Ongoing pain assessment also helps evaluate the client's ability to rest, ambulate, and perform daily activities.

❌ Refer the client for a foot x-ray.

◆ There is no history of trauma or findings suggesting a fracture.

◆ The presentation is more consistent with an acute inflammatory joint disorder.

❌ Request a prescription for antibiotics.

◆ The client has no evidence of bacterial infection, such as fever or purulent drainage.

◆ Antibiotics are not indicated for gout.

❌ Anticipate a prescription for methotrexate.

◆ Methotrexate is used to treat rheumatoid arthritis and certain autoimmune disorders, not acute gout.

◆ It does not relieve inflammation caused by urate crystal deposition.

CBC

◆ A CBC is not routinely monitored to evaluate improvement in gout.

◆ It is more useful when an infection is suspected.

❌ Temperature

◆ Routine temperature monitoring is not the primary indicator of recovery from gout.

◆ Fever would raise concern for septic arthritis, which is not supported by this scenario.

❌ Rash

◆ The client has no rash or vesicular lesions suggestive of shingles.

◆ Monitoring for a rash is not relevant in the management of gout.

🩹 Wound evisceration is a surgical emergency in which internal organs, usually the intestines, protrude through a separated surgical incision.

🚨 The nurse should immediately cover the exposed organs with sterile gauze moistened with warm sterile normal saline to keep the tissues moist and reduce the risk of infection and tissue necrosis.

💧 Moist sterile saline prevents the exposed organs from drying out, which can cause additional tissue damage and compromise blood supply.

📞 After covering the wound, the nurse should notify the surgeon immediately, as the client will require emergency surgical repair.

🛏️ The client should be placed in low-Fowler's position with the knees slightly flexed to decrease tension on the abdominal incision and reduce further protrusion of the organs.

🚫 The nurse should never attempt to push the organs back into the abdomen, as this can cause serious injury and contamination.

🩺 Continue monitoring the client's vital signs for signs of shock, maintain NPO status, and prepare the client for emergency surgery.

✅ Therefore, covering the wound with sterile, saline-soaked gauze is the priority nursing intervention.

❌ Raise the head of the bed to a 45° angle.

🔸 Raising the head of the bed to 45° increases abdominal pressure, which can worsen the evisceration.

🔸 The client should instead be placed in low-Fowler's position with the knees flexed.

🔸 Therefore, this action is incorrect.

❌ Place the client's knees in an extended position.

🔸 Flexing the knees decreases tension on the abdominal muscles and surgical incision.

🔸 Keeping the knees extended increases abdominal strain and may worsen the wound separation.

🔸 Therefore, this intervention is incorrect.

❌ Hold gentle, direct pressure on the protruding organ.

🔸 The nurse should never apply direct pressure to exposed abdominal organs.

🔸 Pressure can damage delicate tissues and compromise blood flow.

🔸 Therefore, this action is contraindicated.

✔ Abdominal dressing

◆ The client's report of "something popped" after coughing, along with a large amount of serosanguinous drainage, is highly suggestive of wound dehiscence, a postoperative emergency.

◆ Dehiscence is the partial or complete separation of a surgical incision, most commonly occurring 5–8 days after surgery, when wound tensile strength is weakest.

◆ Coughing increases intra-abdominal pressure, which can cause weakened wound edges to separate.

◆ A sudden increase in serosanguinous drainage is often the earliest sign of wound dehiscence and may precede evisceration, where abdominal organs protrude through the incision.

◆ The nurse should immediately assess the incision, notify the provider, position the client with the knees slightly flexed, and, if dehiscence is confirmed, cover the wound with sterile saline-moistened dressings while preparing for possible surgical repair.

◆ Prompt intervention is critical to prevent infection, organ injury, and further wound separation.

✔ Heart rate

◆ The client's heart rate has increased from 88/min to 110/min, indicating tachycardia, an early sign of hypovolemia, pain, infection, or developing shock.

◆ In the context of suspected wound dehiscence, tachycardia may reflect blood or fluid loss and the body's compensatory response to maintain tissue perfusion.

◆ The client also has hypotension (98/50 mm Hg) and fever (38.2°C/100.8°F), raising concern for postoperative complications such as sepsis or hemorrhage.

◆ Tachycardia is often one of the earliest indicators of clinical deterioration, making immediate assessment essential.

◆ Continuous monitoring allows the healthcare team to evaluate the client's response to treatment and detect progression toward hemodynamic instability.

✔ Respiratory rate

◆ The respiratory rate has increased from 18/min to 24/min, indicating tachypnea, another early sign of physiological stress.

◆ Tachypnea commonly occurs as the body attempts to compensate for hypoperfusion, infection, pain, or metabolic acidosis.

◆ In a postoperative client with fever, hypotension, tachycardia, and suspected wound dehiscence, an elevated respiratory rate may indicate early sepsis or shock.

◆ Although the client's oxygen saturation remains normal, tachypnea should never be ignored because it often precedes oxygen desaturation during clinical deterioration.

◆ Prompt recognition allows for timely intervention before respiratory compromise becomes more severe.

❌ Pedal pulses

◆ Bilateral pedal pulses are 2+, indicating adequate peripheral circulation.

◆ There is no evidence of impaired perfusion to the lower extremities.

❌ Breath sounds

◆ Breath sounds remain clear and equal bilaterally.

◆ There are no findings suggesting respiratory complications, such as atelectasis or pneumonia.

❌ Oxygen saturation

◆ The oxygen saturation is 95% on room air, which is within an acceptable range.

◆ It does not require immediate intervention at this time.

🩸 Idiopathic thrombocytopenic purpura (ITP) is an autoimmune disorder characterized by low platelet counts, placing the client at increased risk for bleeding.

💉 The MMR vaccine has been associated with rare cases of thrombocytopenia and may worsen or trigger recurrent ITP in susceptible individuals.

⚠️ Because of this risk, MMR vaccination should be withheld or delayed until the healthcare provider determines it is safe to administer.

👩‍⚕️ The nurse should review the client's platelet count, immunization history, and provider recommendations before administering any live vaccine.

📋 The decision to administer MMR should be individualized based on the client's current clinical condition and risk-benefit assessment.

🛡️ Nurses should educate parents to discuss any history of ITP or bleeding disorders before routine immunizations are given.

✅ Protecting the client from vaccine-related complications while maintaining appropriate immunization status is an important nursing responsibility.

✅ Therefore, the MMR vaccine is the scheduled vaccine that should be withheld.

❌ Hepatitis B

🔸 Hepatitis B vaccine is not associated with worsening ITP and is not routinely withheld because of this condition.

🔸 It remains an important vaccine for protection against hepatitis B infection.

🔸 Therefore, this vaccine does not need to be withheld.

❌ Diphtheria and tetanus toxoids and pertussis (DTaP/Tdap)

🔸 DTaP/Tdap vaccines are not specifically contraindicated in clients with ITP.

🔸 Although intramuscular injections may require precautions in clients with severe thrombocytopenia, the vaccine itself is not routinely withheld because of ITP.

🔸 Therefore, this is not the correct answer.

❌ Polio

🔸 The inactivated polio vaccine (IPV) is not associated with causing or worsening ITP.

🔸 It is routinely administered according to the recommended immunization schedule unless another contraindication exists.

🔸 Therefore, this vaccine should not be withheld.

😷 Tuberculosis (TB) is transmitted through airborne droplet nuclei, which remain suspended in the air for long periods and can be inhaled by others.

🫁 An N95 respirator is required when providing routine care for a client with suspected or confirmed pulmonary tuberculosis because it filters out airborne particles.

🏥 Clients with active TB should be placed in an airborne infection isolation room (AIIR) with negative-pressure ventilation to prevent the spread of infectious organisms.

👩‍⚕️ The nurse should wear a fit-tested N95 respirator before entering the client's room and remove it only after leaving the room and closing the door.

📋 The client should wear a surgical mask when leaving the room for essential diagnostic tests or procedures to reduce transmission.

🛡️ Airborne precautions remain in place until the client is no longer infectious, as determined by the healthcare provider and facility policy.

✅ Proper use of an N95 respirator protects healthcare workers from inhaling infectious airborne particles and significantly reduces the risk of TB transmission.

✅ Therefore, an N95 respirator is the appropriate personal protective equipment for routine care of a client with tuberculosis.

❌ Sterile gloves

🔸 Sterile gloves are not required for routine care of clients with tuberculosis.

🔸 Clean gloves are used only when contact with blood, body fluids, or contaminated materials is anticipated.

🔸 Therefore, sterile gloves are not the required PPE for airborne precautions.

❌ Surgical mask

🔸 A surgical mask does not adequately filter airborne droplet nuclei and does not provide sufficient protection against TB.

🔸 Surgical masks are worn by the client when leaving the isolation room, not by healthcare workers providing routine care.

🔸 Therefore, this is not the correct PPE for the nurse.

❌ Shoe protectors

🔸 Shoe protectors are not recommended as routine PPE for tuberculosis.

🔸 They do not protect against airborne transmission of Mycobacterium tuberculosis.

🔸 Therefore, shoe protectors are unnecessary for routine TB care.

✔ Malabsorption

◆ A positive sweat chloride test confirms the diagnosis of cystic fibrosis (CF), an autosomal recessive disorder affecting the exocrine glands.

◆ In CF, thick, sticky secretions obstruct the pancreatic ducts, preventing digestive enzymes from reaching the small intestine.

◆ Without adequate pancreatic enzymes, the child is unable to properly digest and absorb fats, proteins, and fat-soluble vitamins (A, D, E, and K).

◆ The child's manifestations of being "always hungry", weight loss, and a mildly distended abdomen are classic signs of malabsorption despite an increased appetite.

◆ Untreated malabsorption can lead to poor growth, nutritional deficiencies, delayed development, and failure to thrive.

◆ Management includes pancreatic enzyme replacement therapy, a high-calorie, high-protein diet, and supplementation of fat-soluble vitamins to support normal growth and nutrition.

✔ Chronic respiratory infections

◆ Cystic fibrosis causes the production of abnormally thick mucus that accumulates within the airways.

◆ Thick secretions impair mucociliary clearance, making it difficult to remove bacteria and debris from the lungs.

◆ This creates an ideal environment for recurrent bacterial infections, chronic inflammation, and progressive lung damage.

◆ The child's persistent cough and bilateral wheezing are early respiratory manifestations of CF.

◆ Over time, children with CF commonly develop recurrent pneumonia, chronic bronchitis, bronchiectasis, and declining pulmonary function.

◆ Preventing respiratory infections is a major goal of treatment and includes airway clearance techniques, inhaled medications, regular exercise, and prompt antibiotic therapy when indicated.

❌Bone marrow failure

◆ Bone marrow failure is not associated with cystic fibrosis.

◆ CF primarily affects the respiratory, gastrointestinal, and reproductive systems.

❌Hypernatremia

◆ Although children with CF lose excess sodium and chloride in sweat, hypernatremia is not a common long-term complication.

◆ The hallmark diagnostic finding is an elevated sweat chloride level, not persistent hypernatremia.

❌Excessive weight gain

◆ Children with CF are more likely to experience poor weight gain and failure to thrive because of malabsorption.

◆ Excessive weight gain is not expected in untreated cystic fibrosis.