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","B","F","G","H"]

Explanation

A. Beer consumption, particularly in excess, has been associated with an increased risk of gout due to its high purine content, which can lead to elevated uric acid levels in the body. Uric acid is a key factor in the development of gout, as it can crystallize and deposit in the joints, causing inflammation and pain.
B. Hypertension is a risk factor for gout, as it is often associated with other metabolic abnormalities, such as insulin resistance and obesity, which can contribute to elevated uric acid levels. Additionally, certain antihypertensive medications, such as diuretics, can increase the risk of gout by raising uric acid levels in the blood.
F. Type 2 diabetes mellitus is a metabolic disorder characterized by insulin resistance and high blood sugar levels. Insulin resistance is associated with increased uric acid production and reduced renal excretion of uric acid, both of which can contribute to the development of gout.
G. Osteoarthritis is a degenerative joint disease characterized by the breakdown of cartilage in the joints. Studies have shown that individuals with osteoarthritis are at an increased risk of developing gout, possibly due to shared risk factors such as obesity and metabolic syndrome, as well as joint damage and inflammation.
H. Obesity is a significant risk factor for gout, as excess body weight is associated with increased uric acid production and decreased renal excretion of uric acid. Adipose tissue (fat cells) can also produce substances that promote inflammation and contribute to insulin resistance, further increasing the risk of gout in obese individuals.
Incorrect;
C. While sleep apnea has been associated with various metabolic and cardiovascular disorders, its direct association with gout risk is less clear. However, sleep apnea may indirectly contribute to gout risk through its association with obesity and metabolic syndrome.
D. While NSAIDs like ibuprofen can be used to manage acute gout attacks, their use alone is not considered a risk factor for developing gout.
E. Daily aspirin use is not typically associated with an increased risk of gout. In fact, low-dose aspirin is often recommended for individuals at risk of cardiovascular events, including those with gout, to reduce the risk of blood clots and heart attacks.
I. Smoking is not directly associated with an increased risk of gout. However, smoking is a known risk factor for various cardiovascular and respiratory conditions, as well as certain cancers.

A. The client’s blood pressure reading will be less than 160/90 mm Hg. B. The client's daily blood pressure will be less than 140/80 mm Hg this month. C. The client's family will repeat signs and symptoms about the disease. D. The nurse will encourage the client to walk thirty minutes every day.

Correct Answer is B

Explanation

A. While this is a good goal, it's not the most stringent and may not adequately control blood pressure to prevent further complications.
B. This is a more specific and achievable goal for a client with newly diagnosed hypertension. It aligns with recommended blood pressure targets for optimal cardiovascular health.
C. While education and reinforcement of disease signs and symptoms are important aspects of care for clients with cardiovascular disease, this outcome does not directly address the client's current concern of blurred vision or contribute to the management of cardiovascular disease- related complications such as hypertension.
D. Regular physical activity, such as walking, is an essential component of cardiovascular disease management and can help improve blood pressure control and overall cardiovascular health.
However, while exercise promotion is an important aspect of care, it does not specifically address the client's immediate concern of blurred vision or the need for blood pressure management.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits Which finding(s) in the client's health record should the nurse recognize places the client at a greater risk of developing gout? Select all that apply.

Correct Answer is ["A","B","F","G","H"]

Explanation

The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?

Correct Answer is B

Explanation

Patient Data Exhibits After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.

The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. Which action should the nurse take?

A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing care plan?

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

A client with a renal calculus reports severe right flank pain, nausea, and vomiting. Which nursing problem has the highest priority?

A client with stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a 0 to 10 scale. Which intervention should the nurse implement?