A nurse is caring for a 24-year-old female client who was admitted to the emergency unit following a horseback riding accident.
Increase the propofol infusion
Assess the client's pain
Notify the social worker the client is awake
Have the client sign consent forms for procedures already performed
Consider extubating the client
Determine the client’s decision-making ability
Decrease the noise and light stimuli in the room as much as possible
Explain all procedures
Correct Answer : B,F,G,H
Choice B rationale: Assessing the client's pain is crucial as the client becomes more aware. Pain management is essential for comfort and recovery. As the client wakes up, they may begin to experience pain and discomfort, which should be promptly addressed.
Choice F rationale: Determining the client’s decision-making ability is important as the client wakes up to assess their cognitive status and ability to participate in their own care decisions. This helps in planning further care and interventions appropriately.
Choice G rationale: Decreasing the noise and light stimuli in the room as much as possible helps to create a calm environment, which is important for a patient recovering from trauma and surgery. It helps reduce anxiety and agitation as the client becomes more aware of their surroundings.
Choice H rationale: Explaining all procedures is essential for the client’s understanding and cooperation. Clear communication helps reduce anxiety and ensures that the client knows what to expect, which is important for their overall comfort and trust in the healthcare team.
Choice A rationale: Increasing the propofol infusion is incorrect because it is necessary to assess the client’s awareness and response to the current sedation level. Over-sedating the client can delay recovery and obscure their neurological status.
Choice C rationale: Notifying the social worker the client is awake is not immediately necessary at this stage. The focus should be on the client's medical and physical condition first.
Choice D rationale: Having the client sign consent forms for procedures already performed is inappropriate because the client may not be in a suitable mental state to provide informed consent due to recent sedation and trauma.
Choice E rationale: Considering extubating the client is premature. The decision to extubate should be based on a thorough assessment of the client’s readiness, including their ability to maintain their airway and adequate ventilation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Advancing from clear liquids as tolerated is important for the patient’s nutritional intake and postoperative recovery. However, it is not the most urgent task upon admission from the PACU. The nurse must first address immediate needs such as infection prevention and monitoring vital signs before considering dietary advancements. This step can be implemented once the patient’s initial postoperative stability is confirmed.
Choice B rationale
Administering cefazolin 1 gram IV every 6 hours is critical for preventing postoperative infections, especially in patients with surgical wounds. Prophylactic antibiotics are essential in reducing the risk of surgical site infections, which can lead to severe complications. Timely administration of antibiotics helps maintain therapeutic levels in the bloodstream, providing effective coverage against potential pathogens and promoting a positive postoperative outcome.
Choice C rationale
Straight catheterization if unable to void is important for managing urinary retention and preventing bladder distention. However, this intervention should be based on the patient’s condition and the amount of time since the last voiding. It is not the most urgent action upon admission from the PACU unless the patient is exhibiting signs of significant discomfort or bladder distention. Monitoring the patient’s urinary output is important but should follow the administration of prophylactic antibiotics.
Choice D rationale
Completing a blood cell count (CBC) in the morning is important for assessing the patient’s overall health and detecting any potential complications such as anemia or infection. However, it is not the most urgent action upon admission from the PACU. The nurse should prioritize tasks that address immediate postoperative needs, such as administering antibiotics and monitoring vital signs, before scheduling routine blood tests.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Rechecking all vital signs, including core temperature, is essential to assess the client's overall status and identify any changes that may indicate a worsening condition or complications such as infection.
Choice B rationale
Applying oxygen via nasal prongs at 4 L/minute helps ensure adequate oxygenation, which is crucial for patients who may be experiencing postoperative complications, including fever and increased metabolic demand.
Choice C rationale
Continuing to monitor vital signs every hour is important to detect any further changes in the patient's condition and provide timely interventions if needed. Frequent monitoring allows for close observation of trends.
Choice D rationale
Exposing the client's extremities and applying ice packs to the axilla can help reduce fever by promoting heat loss. This intervention is beneficial in managing elevated body temperature and preventing complications associated with hyperthermia.
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