The nurse is assessing the status of a post-operative client in the PACU. The nurse should be most concerned with which assessment finding?
Blood pressure 110/70
heart rate 86
Hypoactive bowel sounds
Increased restlessness
Negative Homan's sign
Correct Answer : D
a. Blood pressure 110/70: This is within normal range for many individuals and is not immediately concerning in the post-operative context.
b. heart rate 86: This is a normal heart rate for most individuals and is not concerning post-operatively.
c. Hypoactive bowel sounds: Hypoactive bowel sounds are common post-operatively due to anesthesia and are not immediately concerning.
d. Increased restlessness Increased restlessness can be a sign of pain, anxiety, hypoxia, or other complications and should be addressed promptly.
e. Negative Homan's sign: A negative Homan’s sign indicates no apparent deep vein thrombosis and is a positive finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. 1030-1130: Insulin aspart is a rapid-acting insulin that typically peaks in 1-2 hours. Hypoglycemia is most likely to occur during the peak action time.
b. 1130-1230: This is beyond the typical peak action time for insulin aspart, making hypoglycemia less likely during this interval.
c. 1000: This falls within the typical peak action time of 1-2 hours for insulin aspart, making hypoglycemia possible but the interval is slightly too narrow to capture the full peak effect.
d. 0800-0830: Insulin aspart begins to act within 10-20 minutes, but hypoglycemia typically does not occur this soon after administration unless there is an issue with meal timing or dosage.
Correct Answer is A
Explanation
a. Establish rapport and develop treatment goals: During the orientation phase, the primary focus is on building trust and rapport with the client. Establishing rapport and developing treatment goals are essential to creating a therapeutic alliance and setting the stage for effective treatment.
b. Acknowledge the client's actions, and generate alternative behaviours: This action is more appropriate during the working phase, where the nurse and client work on behavior change and coping strategies.
c. Explore how thoughts and feelings about this client may adversely impact nursing care: This is part of the nurse's self-reflection and supervision but is not the priority during the orientation phase.
d. Attempt to find alternative placement: This may be considered if the current setting is unsuitable, but it is not the primary focus of the orientation phase.
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