The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes vital signs of a heart rate of 140 beats/minute, a respiratory rate of 26 breaths/minute, and a blood pressure of 140/90 mm Hg. Which intervention is most important for the nurse to implement?

Administer IV fluid bolus as prescribed by the healthcare provider.

Encourage the client to splint the Incision with a pillow to cough and deep breathe.

Medicate for pain and monitor vital signs according to protocol.

Apply oxygen at 10 L/minute via non-rebreather mask and monitor pulse oximeter.

Answer and Explanation

The Correct Answer is C

C.Although postoperative pain can cause a similar presentation, pain management is not the priority intervention.

D. The client's vital signs of tachycardia, tachypnea, and elevated blood pressure suggest potential respiratory distress or inadequate oxygenation following the thoracotomy. Applying oxygen at a high flow rate via a non-rebreather mask can help improve oxygenation and support the client's respiratory function.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"B"}}

Explanation

In an asthmatic attack, exposure to triggers leads to bronchospasm which blocks airflow leading to impaired ventilation that manifests as respiratory distress- tachypnea. This prevents oxygenation with resultant hypoxia as evidenced by low SPO2 levels. Continuous use of a non- selective beta agonists leads to elevated heart rate.

Acute asthmatic attacks are not associated with changes in blood pressure

Acute asthmatic attacks are not associated with changes in temperature. However, when triggered by pulmonary infections, the client may experience episodes of fever.

A. Administer antiemetic B. Monitor for adverse reaction to antibiotics C. Increase IV fluids to 150 mL/hr D. Initiate airborne isolation E. Repeat CD4+ T-cell count STAT

Correct Answer is ["A","B","C"]

Explanation

A. The client is noted to have emesis which contributes to total fluid loss predisposing the client to acute kidney injury. Antiemetics are important to reduce emesis.
B. Clients with PCP are typically treated with antibiotics, such as trimethoprim-sulfamethoxazole (TMP-SMX), as first-line therapy. Monitoring for adverse reactions to antibiotics, such as hypersensitivity reactions or renal toxicity, is essential for safe medication administration.
Increasing fluid intake prevents and manages acute kidney injury in the client.
C. Increasing intravenous hydration ensures the lost fluid is replaced to prevent acute renal injury that may occur due to hypoperfusion.
D. Pneumocystis pneumonia is caused by the fungus Pneumocystis jirovecii (formerly known as Pneumocystis carinii), and its transmission occurs through the inhalation of airborne fungal spores. However, it is not typically spread from person to person like airborne viral or bacterial infections.
E. Repeating CD4 count is not necessary as it is unlikely to alter the management of the client at this point. This should be after 2-3 weeks.

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Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"B"}}

Explanation

Exhibits What order(s) should the nurse anticipate being prescribed after an update is reported to the healthcare providers? Select all that apply.

Correct Answer is ["A","B","C"]

Explanation

A client presents to the emergency department reporting chest pain that is radiating to the left arm, shortness of breath, and diaphoresis. Which medication should the nurse anticipate being prescribed by the healthcare provider?

The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?

Which findings during the admission assessment should the nurse document that are related to a client diagnosed with Cushing's syndrome?

A client is diagnosed with chronic kidney disease and needs to begin dialysis. Which condition entered on the client's medical record should the nurse recognize as a contraindication for peritoneal dialysis?

An adult client who was recently diagnosed with glaucoma tells the nurse, "It feels like I am driving through a tunnel." The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide this client?