Nokea
The post-anesthesia care nurse is caring for the client diagnosed with lung cancer who had a thoracotomy and is experiencing frequent premature ventricular contractions (PVCs). Which intervention should the nurse implement first?
- A. Request STAT arterial blood gases.
- B. Administer lidocaine intravenous push.
- C. Assess for possible causes.
- D. Request a STAT electrocardiogram.
Correct Answer: C
Rationale: Frequent PVCs post-thoracotomy may stem from hypoxia, electrolyte imbalances, or pain. Assessing for causes (C) is the first step to identify and address the underlying issue. ABGs (A) or ECG (D) may follow based on findings. Lidocaine (B) is premature without identifying the cause.
You may also like to solve these questions
Which nursing action is most appropriate immediately after the chest tube is removed from the client?
- A. Apply a sterile dressing and tape it securely.
- B. Request a chest X-ray to assess lung fields.
- C. Administer oxygen by nasal cannula.
- D. Encourage the client to cough vigorously.
Correct Answer: A
Rationale: Applying a sterile dressing taped securely prevents air entry into the pleural space and promotes healing post-chest tube removal.
The client diagnosed with ARDS is on a ventilator and the high alarm indicates an increase in the peak airway pressure. Which intervention should the nurse implement first?
- A. Check the tubing for any kinks.
- B. Suction the airway for secretions.
- C. Assess the lip line of the ET tube.
- D. Sedate the client with a muscle relaxant.
Correct Answer: A
Rationale: High airway pressure may result from kinks (A), a common cause requiring immediate check. Suctioning (B), lip line (C), and sedation (D) follow if needed.
A patient is receiving continuous IV Heparin for anticoagulation therapy for the treatment of a DVT. In order for this medication to have a therapeutic effect on the patient, the aPTT should be?
- A. 0.5-2.5 times the normal value range
- B. 2-3 times the normal value range
- C. 1.5-2.5 times the normal value range
- D. 1-3.5 times the normal value range
Correct Answer: C
Rationale: An aPTT should be 1.5-2.5 times the normal value range for Heparin to achieve a therapeutic effect in a patient to prevent blood clots. If the aPTT is too low, blood clots can form. If the aPTT is too high, bleeding can occur.
Which finding best indicates that the sponge bath is having a therapeutic effect on the client?
- A. The client feels more comfortable.
- B. The client begins sweating profusely.
- C. The client's temperature is 101°F (38.3°C).
- D. The client's skin is flushed.
Correct Answer: C
Rationale: A reduced temperature (101°F) directly indicates the sponge bath is effectively lowering the client's fever.
Which instruction regarding the prescribed medication is most appropriate to tell this client?
- A. Do not take the drug more frequently than prescribed.
- B. Avoid taking the medication before going to sleep.
- C. Drink more fluid throughout the day.
- D. Warm the cough syrup to make it more palatable.
Correct Answer: C
Rationale: Drinking more fluids enhances the expectorant effect of guaifenesin, helping to thin and expel mucus.