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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Allergy to eggs is not a contraindication for taking chondroitin with glucosamine. These supplements do not contain eggs and are generally safe for individuals with egg allergies.
Choice B rationale:
Hypotension is not directly related to the use of chondroitin with glucosamine. These supplements are not known to cause significant changes in blood pressure.
Choice C rationale:
History of hypoglycemia is not a specific concern with chondroitin and glucosamine supplements. These supplements do not significantly impact blood sugar levels in people without diabetes.
Choice D rationale:
The correct choice. The nurse should instruct the client to use chondroitin with glucosamine with caution if they are on anticoagulant therapy. Chondroitin and glucosamine may have mild anticoagulant effects, and when combined with prescribed anticoagulant medications, there is a potential risk of increased bleeding or altered blood clotting times. It is essential to monitor the client's coagulation parameters closely if they decide to use these supplements.
Correct Answer is B
Explanation
Choice A rationale:
An INR (International Normalized Ratio) of 0.8 is within the normal range for someone not on anticoagulation therapy. The aPTT (activated partial thromboplastin time) of 85 seconds is prolonged, but it is not a reason to withhold heparin in itself. Therefore, the nurse should not withhold the medication for these values.
Choice B rationale:
An INR of 2 indicates the client's blood is taking twice as long to clot compared to the average, which can increase the risk of bleeding. The aPTT of 60 seconds is within the normal range. However, the elevated INR suggests the client might be overly anticoagulated, so the nurse should withhold the medication and notify the provider.
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