A nurse is caring for a client who had a surgical repair of an abdominal aortic aneurysm 3 days ago. The client's vital signs are temperature 38.3°C (100.9°F), heart rate 80/min, respirations 16/min, and blood pressure 128/76 mm Hg. Which of the following actions is the nurse's priority?
Notify the surgeon of the temperature elevation.
Encourage the client to drink more fluids.
Assess the surgical incision for signs of infection.
Monitor vital signs every 4 hr.
The Correct Answer is C
Choice A rationale:
Notifying the surgeon of the temperature elevation is important, but it is not the nurse's priority. A temperature elevation after abdominal surgery could be a sign of infection, but the immediate action should be to assess the surgical incision for any signs of infection.
Choice B rationale:
Encouraging the client to drink more fluids is a good practice to maintain hydration and promote recovery after surgery. However, it is not the nurse's priority in this situation. The elevated temperature and potential infection take precedence over increasing fluid intake.
Choice C rationale:
This is the correct answer because the nurse's priority is to assess the surgical incision for signs of infection. An elevated temperature is a significant finding after surgery, and it may indicate a surgical site infection, which requires prompt assessment and intervention.
Choice D rationale:
Monitoring vital signs every 4 hours is an essential nursing intervention after surgery, but it is not the priority when the client has an elevated temperature and a recent surgical incision.
The nurse must first assess for signs of infection before proceeding with routine vital sign monitoring.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
A decrease in NG tube drainage indicates that the client's stomach contents are not being aspirated excessively, which suggests that the IV fluids are effectively maintaining fluid volume balance. This finding is positive because it shows that the client is retaining the fluids they need, and it may also indicate improved gastrointestinal function and decreased risk of dehydration.
Choice B rationale:
The potassium level of 3.3 mEq/L (milliequivalents per liter) is low. The normal range for potassium is typically between 3.5 to 5.0 mEq/L. Hypokalemia (low potassium) can result from various factors and may cause muscle weakness, cardiac arrhythmias, and other complications. It is not a finding that indicates the effectiveness of fluid volume balance therapy.
Choice C rationale:
An increased heart rate may suggest that the client is experiencing fluid volume deficit or other physiological stress. It is not a finding that indicates the effectiveness of fluid volume balance therapy.
Choice D rationale:
A hematocrit level of 46% is within the normal range for adult males (typically around 38.8% to 50%) and indicates the proportion of red blood cells in the blood. While it can provide information about blood viscosity and hydration status, it does not directly indicate the effectiveness of fluid volume balance therapy.
Correct Answer is B
Explanation
Choice A rationale:
Providing a continuous passive motion (CPM) device is not necessary for a client following a total hip arthroplasty. CPM devices are more commonly used after knee arthroplasty to improve joint mobility.
Choice B rationale:
Ensuring the client has an elevated toilet seat at home is important following a total hip arthroplasty. The elevated seat reduces the amount of hip flexion required during toileting, which helps prevent hip dislocation and strain on the surgical site.
Choice C rationale:
Providing a trapeze bar is not essential for a client following a total hip arthroplasty. Trapeze bars are typically used to assist with repositioning in bed for clients with limited mobility, but they are not specific to hip arthroplasty recovery.
Choice D rationale:
Providing a compression garment is not necessary after total hip arthroplasty. Compression garments are often used for conditions like venous insufficiency or to manage swelling, but they are not routinely used for hip arthroplasty recovery.
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