A nurse is caring for a patient in the post-anesthesia care unit (PACU) who underwent a procedure two hours ago.
The nurse observes the following vital signs: heart rate 140 beats/minute, blood pressure 140/90 mm Hg, and respirations 26 breaths/minute.
Which intervention is most important for the nurse to implement?
Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter.
Medicate for pain and monitor vital signs according to protocol.
Encourage the client to splint the incision with a pillow to cough and deep breathe.
Administer intravenous fluid bolus as prescribed by the healthcare provider.
The Correct Answer is A
Choice A rationale
Applying oxygen at 10 L via non-rebreather mask and monitoring pulse oximeter is the most important intervention for a patient in the post-anesthesia care unit (PACU) with a heart rate of 140 beats/minute, blood pressure 140/90 mm Hg, and respirations 26 breaths/minute.
These vital signs suggest that the patient may be experiencing hypoxia or respiratory distress, conditions that require immediate intervention.
Choice B rationale
Medicating for pain and monitoring vital signs according to protocol is important in the PACU, but it is not the most critical intervention in this scenario. The patient’s vital signs suggest a possible respiratory issue, which should be addressed immediately.
Choice C rationale
Encouraging the client to splint the incision with a pillow to cough and deep breathe is a common postoperative intervention to promote lung expansion and prevent atelectasis and pneumonia. However, in this scenario, the patient’s vital signs suggest a more immediate respiratory issue that requires prompt intervention.
Choice D rationale
Administering an intravenous fluid bolus as prescribed by the healthcare provider can be an appropriate intervention for certain conditions in the PACU, such as hypotension. However, in this scenario, the patient’s vital signs suggest a possible respiratory issue, which should be addressed immediately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A lumbar puncture is a key diagnostic procedure for suspected bacterial meningitis. It allows for the collection of cerebrospinal fluid, which can be analyzed for signs of bacterial infection.
Choice B rationale
Skull radiography is not typically used to diagnose bacterial meningitis. While it can help identify abnormalities in the structure of the skull or brain, it cannot detect the presence of bacteria.
Choice C rationale
While an MRI can provide detailed images of the brain and surrounding tissues, it is not the primary tool for diagnosing bacterial meningitis. It may be used in conjunction with other tests, but a lumbar puncture is more definitive.
Choice D rationale
A CT scan can be used to detect abnormalities in the brain, such as swelling or inflammation, which could be indicative of meningitis. However, it cannot definitively diagnose bacterial meningitis.
Correct Answer is B
Explanation
Choice A rationale
Starting an intravenous infusion for antiviral drug administration is premature at this stage. The patient’s COVID-19 test results are not yet available, and antiviral drugs should not be administered without a confirmed positive test.
Choice B rationale
Moving the patient to a private room, keeping the door closed, and initiating droplet precautions is the most important action. Given the patient’s symptoms and the significant other’s COVID-19 status, these measures will help prevent potential spread of the virus.
Choice C rationale
Notifying the charge nurse for assignment to the COVID-19 specified area of the facility is important, but it is not the immediate priority. The first step should be to initiate droplet precautions to minimize the risk of transmission.
Choice D rationale
While it is important to inform the patient about potential exposure, the immediate priority is to prevent the spread of the virus within the healthcare facility.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today