A nurse is collecting data on a patient who is postoperative following aortic valve replacement. Which of the following tasks should the nurse prioritize during data collection?
Check the level of the client's pain.
Check the client's blood pressure.
Check the client's bowel sounds.
Check the client's catheter insertion site.
The Correct Answer is A
Choice A reason: Pain assessment is a critical priority for postoperative patients. After aortic valve replacement surgery, patients may experience discomfort or pain related to the incision site, chest tube placement, or other surgical interventions. Pain assessment allows the nurse to evaluate the effectiveness of pain management strategies, adjust medications as needed, and ensure the patient's comfort and well-being. Pain can also impact vital signs and overall recovery, so addressing it promptly is essential.
Choice B reason: Monitoring blood pressure is important, but it is not the highest priority immediately after surgery. Blood pressure assessment is part of routine postoperative care, but it does not directly address the patient's immediate comfort or potential complications. However, if the patient's blood pressure becomes significantly abnormal, it would require immediate attention.
Choice C reason: Checking bowel sounds is relevant for assessing gastrointestinal function, but it is not the top priority immediately postoperatively. Bowel sounds may be diminished initially due to anesthesia, surgical manipulation, or bowel rest. However, assessing pain and other vital signs takes precedence over bowel sounds in the immediate recovery period.
Choice D reason: Assessing the catheter insertion site is essential, especially if the patient has an indwelling urinary catheter. However, it is not the highest priority immediately after aortic valve replacement. Pain assessment and monitoring for complications related to surgery (such as bleeding, infection, or cardiac issues) take precedence. The catheter site can be assessed during routine nursing care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Cough is not commonly associated with atenolol. Atenolol is a beta-blocker used to treat hypertension and is less likely to cause respiratory side effects compared to some other classes of antihypertensive medications.
Choice B reason: Bradycardia, or a slower than normal heart rate, is a well-documented adverse effect of atenolol. Atenolol works by blocking beta-1 receptors in the heart, which can reduce the heart rate. Normal heart rate ranges for infants (1 to 11 months old) are 80-160 beats per minute (BPM), and for toddlers (1-2 years old), it's 80-130 BPM. Bradycardia would be defined as a heart rate below these normal ranges. It is important for patients starting atenolol to monitor their pulse regularly and report any significant decrease in heart rate to their healthcare provider.
Choice C reason: While constipation can be a side effect of many medications, it is not a common adverse effect of atenolol. Atenolol does not typically affect the gastrointestinal system to the extent that it causes constipation.
Choice D reason: Headache is not a typical adverse effect of atenolol. While headaches can occur for a variety of reasons, they are not directly linked to the pharmacological action of atenolol on the cardiovascular system.
Correct Answer is ["B","D","E"]
Explanation
Choice A reason: Monitoring cholesterol levels is essential while taking lisinopril. This medication is an angiotensin-converting enzyme (ACE) inhibitor used to treat high blood pressure, heart failure, and heart attack. Regular monitoring helps assess the impact of lisinopril on lipid levels and overall cardiovascular health. Elevated cholesterol can contribute to heart disease, so monitoring allows for timely interventions and adjustments in treatment.
Choice C reason: Potassium-rich foods are relevant because lisinopril can affect potassium levels. ACE inhibitors may lead to hyperkalemia (high potassium levels), especially in patients with impaired kidney function. Encouraging potassium-rich foods helps maintain a balance and prevent complications.
Choice D reason: Reporting a persistent dry cough is crucial. Lisinopril is associated with a common side effect: a dry, persistent cough. This occurs due to increased levels of bradykinin, a substance affected by ACE inhibitors. If the client experiences this cough, it's essential to notify the doctor for potential medication adjustments.
Choice E reason: Monitoring blood pressure aligns with the purpose of lisinopril. Regular blood pressure checks help assess the effectiveness of the medication in controlling hypertension. Consistent monitoring ensures timely adjustments and prevents complications related to high blood pressure.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.