A nurse is preparing a client for a hip arthroplasty. For which of the following reasons should the nurse assess the client's vital signs?

To determine how the client will tolerate the procedure

To establish a baseline for postoperative assessment

To prevent postoperative hypotension

To assess the client's pain level

Answer and Explanation

The Correct Answer is B

A.   Vital signs, including blood pressure, heart rate, respiratory rate, and temperature, provide baseline information about the client's cardiovascular and respiratory status. This assessment helps predict how well the client might tolerate the surgical procedure under anesthesia and monitor for any deviations during the procedure.
B.   Establishing baseline vital signs before surgery provides a comparison point for monitoring the client's recovery and identifying any postoperative complications. Changes in vital signs postoperatively can indicate potential issues such as bleeding, fluid imbalance, or respiratory compromise.
C.   Monitoring blood pressure before surgery helps identify clients at risk for intraoperative hypotension, particularly important during induction of anesthesia and throughout the surgical procedure. Establishing baseline blood pressure levels guides intraoperative management to maintain hemodynamic stability.
D.   While vital signs are important for assessing physiological status, they do not directly assess pain. Pain assessment involves asking the client about their pain experience, location, intensity, and factors that alleviate or exacerbate pain. Vital signs can indirectly reflect pain if pain causes changes in heart rate or blood pressure, but they are not specific indicators of pain.

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Correct Answer is C

Explanation

A. Metabolic acidosis is characterized by a decrease in bicarbonate or an increase in acids, which can be caused by conditions like kidney failure or diabetic ketoacidosis, but it is not typically associated with numbness and tingling.
B. Respiratory alkalosis is characterized by a high pH (>7.45) and a decreased PaCO2 (<35 mm Hg). It typically results from hyperventilation, which leads to excessive elimination of CO2 and subsequent alkalosis. This condition is less likely to occur in gastroenteritis unless there are other complicating factors such as anxiety or pain causing increased respiratory rate.
C. In the context of gastroenteritis, where there may be a loss of stomach acids through vomiting or diarrhea, the most likely acid-base imbalance would be metabolic alkalosis.
D. Respiratory acidosis is characterized by a low pH and an elevated PaCO2 (>45 mm Hg). It results from hypoventilation, leading to retention of CO2 and subsequent acidosis. Respiratory acidosis would not typically present with numbness and tingling in the extremities in the context of gastroenteritis.

A. A serum sodium (Na) B. A radiological examination of the chest C. A blood urea nitrogen (BUN) D. An international normalized ratio (INR)

Correct Answer is D

Explanation

A. Serum sodium levels are typically assessed to evaluate electrolyte balance and hydration status. While important for overall health assessment, it is not specifically related to monitoring the effects of warfarin therapy.
B. This could be ordered for various reasons such as assessing lung status or identifying any abnormalities in the chest. It is not directly related to monitoring warfarin therapy.
C. BUN levels are measured to assess kidney function and hydration status. While important for overall health assessment, it is not specifically related to monitoring the effects of warfarin therapy.
D. The INR is a standardized measurement of the blood's ability to clot. Warfarin works by inhibiting vitamin K-dependent clotting factors, thereby prolonging the time it takes for blood to clot. The INR is used to monitor and adjust warfarin dosage to maintain therapeutic anticoagulation levels, especially in patients with conditions like atrial fibrillation who are at risk of blood clots.

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A nurse is preparing a client for a hip arthroplasty. For which of the following reasons should the nurse assess the client's vital signs?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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