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

Answer and Explanation

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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Correct Answer is B

Explanation

B. Obtaining blood and urine specimens for culture and sensitivity is a critical first step. These specimens help identify the causative organism(s) and determine their susceptibility to antibiotics, guiding appropriate antibiotic therapy. Prompt initiation of targeted antibiotic treatment is essential in managing sepsis effectively.
A. This action is important for assessing the presence of any urinary tract stones or debris, which can be helpful in diagnosing the cause of the urinary tract infection. However, it is not the first action the nurse should take in managing a client admitted with sepsis secondary to a urinary tract infection.
C. Administering antibiotics before obtaining appropriate cultures may lead to empirical treatment without knowing the specific pathogen causing the infection. It is important to obtain cultures first to guide antibiotic selection and ensure optimal treatment.
D. Contact precautions may be necessary if the client is found to have a multidrug-resistant organism or if there are specific infection control concerns. However, placing the client on contact precautions is not the first action the nurse should take in managing sepsis secondary to a urinary tract infection.

A. Chronic pain B. Impaired urinary elimination C. Risk for bleeding D. Risk for urinary tract injury

Correct Answer is B

Explanation

B. Impaired urinary elimination: This is the priority problem for a client diagnosed with BPH. BPH commonly obstructs the flow of urine out of the bladder, leading to symptoms such as urinary hesitancy, weak urinary stream, incomplete emptying, and urinary retention. Addressing impaired urinary elimination is crucial to prevent complications such as urinary retention, urinary tract infections, and kidney damage.

A. While BPH can cause symptoms such as urinary hesitancy, frequency, urgency, and incomplete emptying, chronic pain is not typically a primary symptom of BPH itself. However, complications of BPH, such as urinary retention or urinary tract infections, may cause discomfort or pain. Addressing pain related to complications of BPH is important but may not be the priority in all cases.
C. While BPH itself does not typically increase the risk of bleeding, procedures used to diagnose or treat BPH, such as transurethral resection of the prostate (TURP), may carry a risk of bleeding. However, this risk is usually managed intraoperatively and postoperatively by healthcare providers. In the absence of specific interventions or procedures with bleeding risks, addressing bleeding may not be the priority for a client with BPH.
D. Urinary tract injury, particularly during surgical procedures to treat BPH, is a potential complication. However, it may not be the priority problem in the absence of planned interventions or procedures.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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