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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale
Encouraging the client to continue their walking routine is a supportive and positive response. This acknowledges the client’s desire to stay active and engage in activities they enjoy despite their osteoarthritis. It promotes a sense of empowerment and independence, which can be important for overall well-being.
Choice B rationale
Advising less weight-bearing to prevent joint destruction may seem logical, but it is not the best advice. Regular exercise, including walking, can actually help manage osteoarthritis by strengthening the muscles around the joints, improving flexibility, and reducing pain.
Choice C rationale
Recommending walking indoors for improved stability and safety might be helpful in some cases, but it is not necessarily the best response. The client has expressed a desire to continue walking in the park with friends, which also has social and mental health benefits.
Choice D rationale
Suggesting a calcium supplement along with continued walking is not the best advice. While calcium is important for bone health, osteoarthritis is not caused by a lack of calcium. It’s a degenerative joint disease that involves the breakdown of cartilage in the joints.

A. Keep the head of the bed elevated until the treatment is completed. B. Instruct the client to drink plenty of fluids during the treatment. C. Monitor the client’s intravenous site hourly during the treatment. D. Administer an antiemetic before starting the chemotherapy.

Correct Answer is C

Explanation

Choice A rationale
Keeping the head of the bed elevated until the treatment is completed is not typically recommended to reduce the risk of vesicant extravasation during intravenous chemotherapy.
Choice B rationale
Instructing the client to drink plenty of fluids during the treatment does not directly reduce the risk of vesicant extravasation. Hydration can help maintain good vein health, but it does not prevent extravasation.
Choice C rationale
Monitoring the client’s intravenous site hourly during the treatment is a key action to reduce the risk of vesicant extravasation. Regular monitoring allows for early detection of any signs of extravasation, such as swelling or redness at the IV site.
Choice D rationale
Administering an antiemetic before starting the chemotherapy can help manage side effects such as nausea and vomiting, but it does not reduce the risk of vesicant extravasation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A young adult client with osteoarthritis of both knees expresses the desire to continue daily walks in the park with friends. How should the nurse respond?

Correct Answer is A

Explanation

Which action should the nurse implement to reduce the risk of vesicant extravasation in the client who is receiving intravenous chemotherapy?

Correct Answer is C

Explanation

The nurse is caring for a client admitted to the hospital with a tentative diagnosis of bacterial meningitis. Which diagnostic procedure should the nurse prepare the client for the healthcare provider?

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A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client’s plan of care?

A patient with a full-thickness burn covering 40% of their body is exhibiting purulent drainage at the wound site. Before reporting this finding to the healthcare provider, which of the patient’s laboratory values should the nurse review?

A patient with gouty arthritis is experiencing tenderness and swelling in the right ankle and big toe. The nurse notes that the inflammation extends above the ankle area. The patient has been prescribed colchicine and indomethacin. What should the nurse include in the discharge teaching?

The nurse is caring for a patient with chronic pancreatitis who reports persistent gnawing abdominal pain. What assessment data is most important for the nurse to obtain to help manage the patient’s pain?

Which group of foods should the nurse recommend for patients with a strong family history of colon and rectal cancers?