CPAN Practice Exam – Comprehensive Guide for Exam Prep

The correct answer highlights significant decreases in blood pressure, a slow heart rate, or a respiratory rate of less than 8 breaths per minute as vital sign changes that necessitate immediate nursing intervention in a post-anesthesia patient.

These changes are critical because they indicate possible serious complications. A significant decrease in blood pressure could be a sign of hypovolemic shock or cardiovascular instability, which requires prompt attention to prevent further deterioration. A slow heart rate, or bradycardia, can be indicative of vagal responses, inadequate oxygenation, or potential drug effects from anesthesia that could lead to severe outcomes if not addressed quickly. Additionally, a respiratory rate of less than 8 breaths per minute signals respiratory depression, which can lead to inadequate oxygenation and carbon dioxide retention, necessitating immediate intervention such as airway management or supplemental oxygen.

In contrast, elevated heart rate accompanied by fever may indicate infection or another physiological response but does not necessarily indicate an immediate life-threatening situation. Increased respiratory effort with stable blood pressure may signify respiratory distress but does not require the same urgent action as severe bradycardia or respiratory depression. Stable heart rate with fluctuating blood pressure could be monitored closely; while fluctuations can be concerning, they do not invoke the need for immediate intervention