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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
A. Metolazone is a thiazide-like diuretic that works primarily in the distal convoluted tubule of the nephron. It can lead to hyponatremia due to its mechanism of increasing sodium and water excretion. However, it is not typically associated with hyperkalemia.
B. Furosemide is a loop diuretic that acts on the ascending loop of Henle. It primarily causes loss of sodium, potassium, and chloride ions. While it can lead to hypokalemia (low potassium levels) due to increased potassium excretion, it does not typically cause hyperkalemia or hyponatremia.
C. Hydrochlorothiazide is a thiazide diuretic that acts on the distal convoluted tubule. It can cause hyponatremia due to increased sodium and water excretion. It may also lead to hypokalemia but is not typically associated with hyperkalemia.
D. Spironolactone is a potassium-sparing diuretic that works by antagonizing aldosterone receptors in the distal nephron, leading to retention of potassium and excretion of sodium. It can cause hyperkalemia due to its potassium-sparing effects. Additionally, it may also lead to hyponatremia, although less commonly than thiazide diuretics.
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