The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider?

The 24-hour oral intake is 600 ml greater than the total output.

The patient's temperature is 100.3" F 137.9" C).

The patient reports abdominal pain at level 6 (0 to 10 scale) when ambulating

The patient's calf is swollen, warm, and painful.

Answer and Explanation

The Correct Answer is D

These symptoms suggest the possibility of deep vein thrombosis (DVT), which is a potentially serious complication following surgery. DVT occurs when a blood clot forms in a deep vein, commonly in the lower extremities. The symptoms of a swollen, warm, and painful calf can indicate the presence of a DVT.

DVT is a medical emergency that requires immediate attention and intervention to prevent further complications such as a pulmonary embolism (where the blood clot travels to the lungs). Prompt evaluation and treatment, such as anticoagulant therapy, are necessary to prevent complications

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Correct Answer is A

Explanation

The patient's vital signs indicate signs of septic shock, including low blood pressure (70/46 mm Hg), tachycardia (136 beats/min), and tachypnea (32 breaths/min). The patient also has a high temperature of 104°F, indicating a fever. These findings suggest a systemic response to an infection that is leading to inadequate tissue perfusion.The initial treatment for septic shock includes fluid resuscitation to improve blood pressure and tissue perfusion. A fluid bolus of 0.9% Sodium Chloride (normal saline) is commonly used to restore intravascular volume in septic shock. It helps to increase blood pressure, improve organ perfusion, and stabilize the patient's condition.

The other interventions, such as administering Pantoprazole (Protonix) for gastrointestinal protection, giving Acetaminophen (Tylenol) for fever control, or administering rapid-acting insulin per sliding scale for hyperglycemia, are important aspects of care but should be implemented after the initial fluid resuscitation. The priority at this moment is to address the patient's hypotension and inadequate tissue perfusion through the administration of fluid bolus.

A. Prevent blood clots B. Prevent malignant hyperthermia. C. Promote fracture healing. D. Reduce pain E. Prevent fat embolism

Correct Answer is ["C","D","E"]

Explanation

The nurse explains that immobilizing a fracture will:

Help align the bone fragments and reduce movement, which is crucial for proper healing. Immobilization can help maintain the stability of the fracture site, allowing the bones to knit together and heal.
Help to minimize movement and subsequent pain. It provides support and reduces stress on the injured area, which can help alleviate discomfort and promote a more comfortable healing process.
Help to minimize movement and reduce the risk of fat globules from bone marrow entering the bloodstream and causing a fat embolism, a potentially serious complication.

Preventing blood clots, preventing malignant hyperthermia, and immobilizing a fracture are not directly related. Preventing blood clots typically involves other measures such as early mobilization, elevation, and medication to prevent deep vein thrombosis. Malignant hyperthermia is a rare, potentially life-threatening reaction to certain medications used during anesthesia, and immobilization does not directly prevent it.

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The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider?

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Naxlex Comprehensive Predictor Exams

A patient with sepsis has a BP of 70/46 mm Hg, pulse of 136 beats/min, respirations of 32 breaths/min, temperature of 104°F, and blood glucose of 245 mg/dL. Which intervention ordered by the health care provider should the nurse implement first?

Correct Answer is A

Explanation

Why it is important to immobilize a suspected fracture. The nurse explains that immobilizing a fracture will... (SELECT ALL THAT APPLY)

Correct Answer is ["C","D","E"]

Explanation

An appropriate nursing intervention to minimize separation anxiety in a hospitalized toddler is to:

A patient is admitted for treatment of Cushing's syndrome. The nurse correlates this disease process to which alteration in endocrine function?

What are the most important nursing interventions for clients with possible renal calculi? List two.

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The nurse is admitting a client diagnosed with acute renal failure (ARF). The nursing assessment will prioritize ...

Which assessment information is most important for the nurse to obtain when evaluating whether treatment of a patient with anaphylactic reaction has been effective?

What is the priority action the nurse will take for a 4-year old client admitted with minimal change nephrotic syndrome (MCNS) who has hypertension and facial edema?