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 D

Explanation

D. Platelets are responsible for primary hemostasis, which involves the initial formation of blood clots to stop bleeding. A low platelet count (thrombocytopenia) or dysfunction in platelet function can lead to bleeding manifestations such as petechiae and ecchymosis.
A. Hemoglobin levels measure the concentration of hemoglobin in the blood and are used to assess for anemia.
B. White blood cell count measures the number of white blood cells in the blood and is used to assess for infections or inflammatory conditions.
C Red blood cell count measures the number of red blood cells in the blood and is used to assess for anemia or erythrocytosis.

A. Remove the medication from the dispensing system. B. Compare the client’s wristband to the medication administration record. C. Document administration of the medication. D. Open the medication package. E. Obtain the client’s apical heart rate.

Correct Answer is E, A, B, D, C

Explanation

Before administering digoxin, the nurse should check the patient's apical heart rate. If the heart rate is below 60 beats per minute for an adult, or below the prescribed limit for a child, the nurse should hold the medication and notify the healthcare provider. This is the first step because the nurse needs to have the medication in hand before proceeding with the other steps. This step is crucial to ensure that the right medication is being given to the right patient. It's a part of the "five rights" of medication administration: right patient, right medication, right dose, right route, and right time. Once the nurse has confirmed the patient's identity and heart rate, the next step is to open the medication package. After administering the medication, the nurse should document it in the patient's medical record. This is important for maintaining an accurate record of the patient's medication history.

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Naxlex Comprehensive Predictor Exams

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

Correct Answer is D

Explanation

A nurse is preparing to administer digoxin orally to a client. Identify the sequence of steps the nurse should take (Move the steps into the box on the right, placing them in the order of performance. Use all the steps)

Correct Answer is E, A, B, D, C

Explanation

The nurse is caring for a client who is receiving teletherapy radiation for a malignant tumor. Which Instruction regarding skin care of the portal site should the nurse provide?

The nurse is performing a physical assessment of a client. Which finding should the nurse recognize is a result of a compromised peripheral arterial circulation of the lower extremity?

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

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.

The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendation should the nurse encourage the client to follow?

A client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client?

The nurse is caring for a client that is unconscious and having seizures. Which nursing intervention is most essential in this client's plan of care (POC)?