Today’s NCLEX-RN® question of the day focuses on the client’s baseline vital signs after surgery. Can you figure it out?
The nurse is assessing a client diagnosed with atelectasis after undergoing a surgical procedure to remove infected pelvic mesh. Based on the client’s baseline vital signs, which finding indicates that the client’s condition is worsening?
Baseline Vital Signs | |
Temperature | 98.9℉ (37.2°C) |
Respiratory Rate | 20/min |
Oxygen Saturation | 92% on room air |
Heart Rate | 75/min |
A. Respiratory rate of 19/min
B. Temperature of 99℉ (37.2℃)
C. Oxygen saturation of 95% on room air
D. Heart rate 109/min
Scroll down for the correct answer!
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The correct answer to today’s NCLEX-RN® Question is…
D. Heart rate 109/min
Rationale: The normal parameters of the heart rate are 60 to 100/min; therefore, a heart rate of 109/min is abnormal and referred to as tachycardia. Tachycardia can occur when there is inadequate gas exchange, therefore, it could indicate the client’s respiratory status is worsening. In addition, when compared to the client’s baseline heart rate, it has increased significantly.
Main takeaway
It is important for the nurse caring for a client diagnosed with atelectasis to recognize signs and symptoms that indicate the client’s condition is worsening. Signs of hypoxia, such as tachycardia, low oxygen saturation, and tachypnea, can indicate that the client is not able to maintain adequate oxygenation on their own.
Incorrect answer explanations
A. Respiratory rate of 19/min
Rationale: The normal adult respiratory rate is between 12 to 20/min; therefore, a respiratory rate of 19/min is a normal finding. In addition, when compared to the client’s baseline respiratory rate, it has decreased.
B. Temperature of 99℉ (37.2℃)
Rationale: A temperature of 99℉ (37.2℃) is within the normal parameter of 97°F (36.1°C) to 99°F (37.2°C). This does not indicate the client’s condition is necessarily worsening; however, the nurse should continue to monitor it since it is slightly higher than the baseline.
C. Oxygen saturation of 95% on room air
Rationale: The normal parameters of the oxygen saturation rate are 95% to 100% on room air. An oxygen saturation rate of 95% is within normal limits and has improved from the client’s baseline.
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