The nurse determines that an adult client who is admitted to the postanesthesia care unit (PACU) following abdominal surgery has a tympanic temperature of 94.6°F (34.8°C), a heart rate of 88 beats per minute, a respiratory rate of 14 breaths per minute, and a blood pressure of 94/68 mm Hg. Which intervention should the nurse implement first?

Check the blood pressure every five minutes for one hour

Take the client's temperature using another method

Raise the head of the bed to 60 to 90 degrees

Ask the client to cough and deep breathe

Answer and Explanation

The Correct Answer is B

Choice A reason: Checking the blood pressure every five minutes for one hour is important, especially if the blood pressure is unstable. However, this action does not address the immediate issue of the client’s low temperature, which needs to be verified and addressed promptly to prevent complications such as hypothermia.

Choice B reason: Taking the client's temperature using another method is crucial. The extremely low tympanic temperature reading may not be accurate, and confirming the client's core body temperature is essential. Hypothermia can lead to serious complications, including altered cardiovascular and respiratory function, and needs to be managed promptly.

Choice C reason: Raising the head of the bed to 60 to 90 degrees is not appropriate in this situation. Elevating the head of the bed is typically done to improve respiratory function or decrease intracranial pressure, but it does not address the potential issue of hypothermia indicated by the low temperature reading.

Choice D reason: Asking the client to cough and deep breathe is a good practice to prevent postoperative complications such as atelectasis, but it is not the priority intervention in this scenario. The immediate concern is verifying the client's temperature to rule out or address hypothermia.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Choice A reason: A fasting serum glucose level of 140 mg/dL (7.77 mmol/L) indicates hyperglycemia, which is elevated but not an immediate life-threatening complication. It suggests poor blood glucose control but does not directly indicate a complication specific to type 2 diabetes and hypertension. This value should prompt further evaluation and adjustments in diabetes management, but it is not as critical as other potential findings.

Choice B reason: A glycosylated hemoglobin (A1c) level of 6.9% is within the range of good diabetic control. While it indicates the client has been managing their blood glucose levels relatively well over the past few months, it does not suggest a current complication. This value is used to assess long-term glucose control rather than acute issues.

Choice C reason: A serum creatinine level of 1.6 mg/dL (141.44 umol/L) is elevated and indicates impaired kidney function. Clients with type 2 diabetes mellitus and hypertension are at increased risk for kidney disease, known as diabetic nephropathy or hypertensive nephropathy. Elevated creatinine levels suggest that the kidneys are not filtering waste products effectively, which is a significant complication that requires immediate attention and intervention.

Choice D reason: A white blood cell (WBC) count of 11,000/mm3 (11 x 10^9/L) is slightly elevated and may suggest an infection or inflammation. However, it is not a specific complication related to type 2 diabetes mellitus and hypertension. Elevated WBC counts warrant further investigation to identify any underlying infection or inflammatory process, but it is not as directly related to diabetic or hypertensive complications as elevated serum creatinine.

A. Take the client to the emergency department (ED) B. Apply the client's home oxygen C. Ensure that the client avoids salt intake for the rest of the day D. Check for a thrill and bruit at the client's dialysis access site

Correct Answer is A

Explanation

Choice A reason: Taking the client to the emergency department is crucial because missing a dialysis session can lead to severe complications such as fluid overload, high potassium levels, and other electrolyte imbalances. These conditions can be life-threatening and require immediate medical attention to stabilize the client.

Choice B reason: Applying home oxygen is not the most critical intervention in this scenario. While oxygen therapy might be necessary in some cases, it does not address the immediate risk of complications arising from missed dialysis.

Choice C reason: Ensuring that the client avoids salt intake for the rest of the day is important for managing fluid balance, but it is not the most urgent action needed in this situation. The client's lethargy and difficulty arousing indicate a more serious underlying issue that requires immediate medical evaluation.

Choice D reason: Checking for a thrill and bruit at the client's dialysis access site is important for assessing the patency of the access site, but it is not the most critical action in this scenario. The immediate concern is the client's lethargy and potential complications from missed dialysis, which necessitate emergency medical care.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A client with chronic kidney disease (CKD) missed dialysis yesterday to attend a funeral. The client's spouse calls the home health nurse and reports that the client is lethargic and hard to arouse. Which instruction is most important for the nurse to provide?

Correct Answer is A

Explanation

A client presents with the onset of a severe headache, fever, nuchal rigidity, and a petechial rash on arms and legs. The nurse recognizes the client is exhibiting symptoms of which condition?a) Cerebrovascular accident (CV

A client who is experiencing a first gouty arthritis attack reports excruciating pain in the right great toe. The nurse inspects the inflamed joint and administers ibuprofen 800mg PO as prescribed. Which instruction should the nurse include in the discharge teaching?

The nurse assesses an adult client 24 hours following abdominal surgery and finds the client's blood pressure is 98/40 mm Hg. The client is tachycardiac, restless, and irritable. Which action should the nurse perform first?

Exhibits After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.

A client who was recently diagnosed with Raynaud's disease is concerned about pain management. Which nursing instruction should the nurse provide?

An adult client newly diagnosed with left ventricular dysfunction is admitted to the hospital with fine rales and wheezing. When assessing this client, which additional finding is the nurse likely to obtain?