The nurse is assessing a client after bariatric surgery. The client complains of chest pain and shortness of breath. What is the priority nursing Intervention at this time?
Sit the client up and provide supplemental oxygen
Contact the physician and obtain an arterial blood gas
Explain that this is an expected finding after surgery
Encourage the use of the incentive spirometer
The Correct Answer is A
A. Sit the client up and provide supplemental oxygen is the correct priority intervention. Chest pain and shortness of breath can be indicative of pulmonary embolism or other respiratory complications, which require immediate attention. Sitting the client up helps improve respiratory mechanics, and providing supplemental oxygen can support oxygenation while further assessments are conducted.
B. While contacting the physician and obtaining an arterial blood gas may be necessary to assess respiratory status and oxygenation, it is not the immediate priority. The client's symptoms require immediate intervention to ensure adequate oxygenation and prevent further deterioration.
C. Chest pain and shortness of breath are not typically expected findings after bariatric surgery and could indicate serious complications. It is essential not to dismiss the client's symptoms but to take them seriously and initiate appropriate interventions.
D. While the use of an incentive spirometer is important for preventing respiratory complications after surgery, it is not the priority intervention in this situation. The client's current symptoms require immediate attention to address potential respiratory distress or other serious complications.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Anuria refers to the absence of urine production, which can occur due to urinary tract obstruction, severe dehydration, or renal failure. In the context of a client attempting to pass a kidney stone, anuria would be a concerning sign indicating potential urinary tract obstruction requiring urgent medical attention.
A. Renal colic refers to severe flank pain caused by the passage of a kidney stone through the urinary tract. While renal colic is a common symptom of kidney stones and can cause significant discomfort, it does not necessarily indicate an emergency situation unless it is associated with complications such as obstructive uropathy or infection.
B. Hematuria, or blood in the urine, is a common finding in individuals with kidney stones. It occurs due to irritation or injury to the urinary tract as the stone passes through.
C. Nausea is a common symptom experienced by individuals with kidney stones, particularly if there is associated pain or discomfort. While nausea can be distressing, it does not typically indicate an emergency situation unless it is severe and persistent, leading to dehydration or other complications.
Correct Answer is C
Explanation
C. Costovertebral tenderness, which is tenderness over the costovertebral angle (where the ribs meet the vertebral column) on palpation, is more indicative of acute pyelonephritis rather than cystitis. In acute pyelonephritis, inflammation of the kidney parenchyma and surrounding tissues can lead to tenderness in this area.

A. Both acute pyelonephritis and cystitis can present with urinary urgency, as it is a common symptom of urinary tract infections (UTIs) in general.
B. Increased WBCs in urinalysis: While an increased number of white blood cells (WBCs) in the urinalysis can indicate a urinary tract infection, it is not specific to either acute pyelonephritis or cystitis.
D. Hematuria can occur in both acute pyelonephritis and cystitis.
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