High School

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Mr. Ferris is a 72-year-old male. He has a history of atherosclerosis and hypertension. He is Post Op Day 1 right total knee replacement. In surgery he required a unit of blood. He was short of breath post op. A chest x-ray was completed and showed pulmonary congestion. The MD ordered Lasix. Patient has mild shortness of breath at rest. His current vital signs are: Temp: 97.8, HR 80, RR 24, BP 162/75 The monitor shows the following: What is the next appropriate action?
1) Call the MD. This patient needs to go to ICU.
2) Prepare and give the Lasix as ordered.
3) Grab the crash cart
4) Seek expert advice (i.e. cardiologist)

Answer :

The most appropriate next action in this scenario is to prepare and give the Lasix as ordered to alleviate pulmonary congestion while continuing to monitor the patient's respiratory status closely. The correct answer is 2) Prepare and give the Lasix as ordered.

In the scenario provided, Mr. Ferris, a 72-year-old male with a history of atherosclerosis and hypertension and recent right total knee replacement surgery, is exhibiting pulmonary congestion and shortness of breath postoperatively. This could indicate the onset of congestive heart failure or fluid overload, possibly exacerbated by the unit of blood he received during surgery. Given his current vital signs, specifically the high blood pressure of 162/75, it is reasonable to start with the most conservative and immediate action under standard nursing protocols, which would be to prepare and give the Lasix as ordered by the physician. Furosemide (Lasix) is a loop diuretic that will help to alleviate the pulmonary congestion by promoting the excretion of excess fluid. However, ongoing monitoring is essential, and if the patient's respiratory status deteriorates or other signs of serious complications arise, immediate escalation of care may be required which can include notifying the physician or seeking advanced care treatments. The correct answer is 2) Prepare and give the Lasix as ordered.

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Rewritten by : Jeany