Nokea
The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes vital signs of a heart rate of 140 beats/minute, a respiratory rate of 26 breaths/minute, and a blood pressure of 140/90 mm Hg. Which intervention is most important for the nurse to implement?
- A. Administer IV fluid bolus as prescribed by the healthcare provider.
- B. Medicate for pain and monitor vital signs according to protocol.
- C. Encourage the client to splint the incision with a pillow to cough and deep breathe.
- D. Apply oxygen at 10 L/minute via non-rebreather mask and monitor pulse oximeter.
Correct Answer: B
Rationale: Medicating for pain and monitoring vital signs is the most important intervention, as the elevated vital signs are likely due to inadequate pain control following a thoracotomy, which can lead to increased sympathetic activity.
You may also like to solve these questions
A client with stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a 0 to 10 scale. Which intervention should the nurse implement?
- A. Alternate IV and IM analgesic medications.
- B. Administer opioid and non-opioid medication simultaneously.
- C. Give maximum dosage when score reaches 10.
- D. Educate client on signs and symptoms of narcotic dependency.
Correct Answer: B
Rationale: Administering opioid and non-opioid medication simultaneously addresses severe pain from multiple pathways, providing effective relief for stage IV bone cancer.
A client who works as a data entry clerk is concerned as to how a recent diagnosis of Raynaud's syndrome is going to affect the client's job performance. Which instruction should the nurse provide this client?
- A. Obtain a keyboard designed to limit wrist flexion.
- B. Use a space heater to keep the workspace warm.
- C. Take a multivitamin that contains vitamin D daily.
- D. Keep both hands elevated during work breaks.
Correct Answer: B
Rationale: Maintaining warmth is crucial for Raynaud's syndrome to prevent vasospastic attacks triggered by cold exposure, ensuring proper blood flow.
A college student comes to the school's health clinic troubled by urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first?
- A. Palpate the right flank for tenderness.
- B. Test the urine for the presence of hematuria.
- C. Evaluate the urine for a strong odor.
- D. Measure the temperature and pulse rate.
Correct Answer: D
Rationale: Measuring temperature and pulse rate is important to identify signs of systemic infection or inflammation contributing to the client's symptoms.
The nurse is preparing a client for surgery who was admitted from the emergency department following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site. During the preoperative assessment, the nurse determines that the client currently receives heparin sodium 5,000 units SUBQ daily. Which nursing action is a priority?
- A. Have the client sign the surgical and transfusion permits.
- B. Notify the healthcare provider of the client's medication history.
- C. Ensure that the potential for bleeding is explained to the client.
- D. Observe the heparin injections sites for signs of bruising.
Correct Answer: B
Rationale: Notifying the healthcare provider of the client's heparin use is crucial to ensure appropriate perioperative management and prevent excessive bleeding during surgery.
Which findings during the admission assessment should the nurse document that are related to a client diagnosed with Cushing's syndrome?
- A. Husky voice and troubled by hoarseness.
- B. Central type obesity, with thin extremities.
- C. Warm, soft, moist, salmon colored skin.
- D. Visible swelling of the neck, with no pain.
Correct Answer: B
Rationale: Central type obesity with thin extremities is a classic manifestation of Cushing's syndrome due to excess cortisol, causing fat accumulation in the trunk and muscle wasting in the extremities.