The nurse is assessing a client in the post-anesthesia care unit. The client's vital signs are T 98°F, P 106, R 24, and BP 88/40. The client is awake and oriented x 3 and the skin is pale and damp. The client denies complaints of pain. What intervention should the nurse implement first?

Start an IV of DSNS with 40 mEq KCI at 125 mL/hr

Elevate the feet and lower the head

Call the surgeon and report the vital signs

Monitor the vital signs every 15 minutes

Answer and Explanation

The Correct Answer is B

A. Start an IV of DSNS with 40 mEq KCI at 125 mL/hr: Starting an IV is important but may not be the immediate first step. The client's symptoms suggest hypotension, likely due to hypovolemia, which needs immediate positional intervention before fluid administration.
B. Elevate the feet and lower the head: This position, known as the Trendelenburg position, helps increase venous return to the heart and can quickly improve blood pressure and perfusion to vital organs. It is an immediate intervention for hypotension.
C. Call the surgeon and report the vital signs: While important, calling the surgeon is not the first intervention. Immediate action to stabilize the client's condition is necessary before notifying the healthcare provider.
D. Monitor the vital signs every 15 minutes: Monitoring is important, but it is not an immediate intervention. The nurse must first address the client's low blood pressure and symptoms of hypoperfusion before continuing regular monitoring.

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Correct Answer is D

Explanation

A. Increased cardiac output: In older adults, cardiac output typically decreases, not increases, and this has a minor impact on nutritional status.
B. An increase in GI motility and absorption: GI motility and absorption generally decrease with age, not increase, which can affect nutritional status.
C. Constant snacking between meals that results in obesity: Obesity is less common in healthy older adults compared to issues related to malnutrition or economic factors.
D. Living alone on a fixed income: This can significantly impact nutritional status due to potential financial constraints affecting food availability and quality.

A. Respiratory acidosis without compensation B. Metabolic acidosis with full compensation C. Respiratory acidosis with partial compensation D. Metabolic acidosis without compensation

Correct Answer is C

Explanation

A. Respiratory acidosis without compensation: The pH of 7.22 indicates acidosis, but the HCO3 level of 23 mEq/L suggests that compensation is occurring because the HCO3 is within the normal range for respiratory acidosis.
B. Metabolic acidosis with full compensation: The high PaCO2 level is more indicative of respiratory issues, not metabolic acidosis. Additionally, compensation for metabolic acidosis would show elevated HCO3.
C. Respiratory acidosis with partial compensation: The elevated PaCO2 and low pH indicate respiratory acidosis. The normal HCO3 level suggests partial compensation by the kidneys.
D. Metabolic acidosis without compensation: The elevated PaCO2 and normal HCO3 suggest respiratory acidosis rather than metabolic acidosis.

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The nurse is assessing a client in the post-anesthesia care unit. The client's vital signs are T 98°F, P 106, R 24, and BP 88/40. The client is awake and oriented x 3 and the skin is pale and damp. The client denies complaints of pain. What intervention should the nurse implement first?

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Naxlex Comprehensive Predictor Exams

When planning nutritional interventions for a healthy 83-year-old man, the nurse recognizes what factor is most likely to affect his nutritional status?

Correct Answer is D

Explanation

An unresponsive client was brought to the emergency room and had an arterial blood gas drawn. Ten minutes later, the laboratory calls with the following results: PaO2 74%, pH 7.22, PaCO2 85 mm Hg, and HCO3 23 mEq/L. The nurse interprets the results as indicating which imbalance?

Correct Answer is C

Explanation

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