A nurse is caring for a client who is 1-day post-total hip replacement surgery. Assessment findings are as follows.

Assessment

Vital Signs BP 112/68 mmHg

Heart rate 75 beats/min. Respirations 18 breaths/min 02 saturation 90%, room air Surgical site clean, dry, intact

Lung sounds clear upper lobes, diminished lower lobes.

Pain 2/10

Which action by the nurse is most appropriate at this time?

Administer the antibiotic earlier than scheduled.

Administer pain medication.

Have the client use the incentive spirometer.

Change the dressing over the wound.

Answer and Explanation

The Correct Answer is C

The assessment findings indicate that the client has diminished lung sounds in the lower lobes, suggesting potential postoperative atelectasis or decreased air movement in the lungs. Using an incentive spirometer can help improve lung expansion and prevent respiratory complications such as pneumonia. It is important to address this issue promptly to prevent further deterioration of lung function.

Administering pain medication may be necessary depending on the client's level of pain, but addressing the respiratory issue takes priority in this situation.

Administering the antibiotic earlier than scheduled or changing the dressing over the wound may not be indicated based on the provided assessment findings.

Therefore, having the client use the incentive spirometer is the most appropriate action at this time to promote optimal lung function and prevent respiratory complications.

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Correct Answer is A

Explanation

The patient's vital signs indicate signs of septic shock, including low blood pressure (70/46 mm Hg), tachycardia (136 beats/min), and tachypnea (32 breaths/min). The patient also has a high temperature of 104°F, indicating a fever. These findings suggest a systemic response to an infection that is leading to inadequate tissue perfusion.The initial treatment for septic shock includes fluid resuscitation to improve blood pressure and tissue perfusion. A fluid bolus of 0.9% Sodium Chloride (normal saline) is commonly used to restore intravascular volume in septic shock. It helps to increase blood pressure, improve organ perfusion, and stabilize the patient's condition.

The other interventions, such as administering Pantoprazole (Protonix) for gastrointestinal protection, giving Acetaminophen (Tylenol) for fever control, or administering rapid-acting insulin per sliding scale for hyperglycemia, are important aspects of care but should be implemented after the initial fluid resuscitation. The priority at this moment is to address the patient's hypotension and inadequate tissue perfusion through the administration of fluid bolus.

Correct Answer is ["1.4"]

Explanation

We know that 7,000 units is equivalent to 5,000 units per ml. So, we can set up the proportion:

7,000 units / 5,000 units per ml = x ml / 1 ml x = 7,000 / 5,000

x = 1.4

Therefore, the nurse should administer 1.4 milliliters (ml) of heparin.

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Naxlex Comprehensive Predictor Exams

A patient with sepsis has a BP of 70/46 mm Hg, pulse of 136 beats/min, respirations of 32 breaths/min, temperature of 104°F, and blood glucose of 245 mg/dL. Which intervention ordered by the health care provider should the nurse implement first?

Correct Answer is A

Explanation

Heparin 7,000 units is ordered. Heparin 5,000 units per ml is available. How many milliliters (ml) should the nurse administer? (Do not round)

Correct Answer is ["1.4"]

Explanation

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