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 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.

A. "I will give you some ice chips instead of a drink of water". B. "I have to assess your gag reflex before giving you any food or water". C. "I will call the primary health care provider and request an order for food and water". D. "Let's try having a small sip of water to see if you can swallow".

Correct Answer is B

Explanation

A. Offering ice chips, might seem like a safe alternative, but it still poses a risk if the gag reflex is not intact.
B. Assessing the gag reflex is crucial before offering food or fluids to ensure the client can protect their airway and swallow safely. This response prioritizes safety and is appropriate to ensure the client does not aspirate.
C. Calling the healthcare provider to request orders for food and water may be necessary if there are specific protocols or if the client's condition requires further assessment or interventions before oral intake can be resumed. However, this response does not address the immediate need for comfort and hydration.
D. This response involves assessing the client's ability to swallow directly. While it addresses the client's request for water, it may not be the safest initial approach without first assessing the client's readiness and ability to swallow safely.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a preoperative client. The client has a history of atrial fibrillation and is taking warfarin daily. Which test order will the nurse request from the provider?

Correct Answer is D

Explanation

A client returns to the unit after having a bronchoscopy. The client states "my throat is so dry. Can I have a glass of water?". How will the nurse respond?

Correct Answer is B

Explanation

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