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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Cushing's syndrome often leads to central (truncal) obesity, characterized by fat accumulation around the abdomen and face, while the extremities may appear relatively thin due to muscle wasting. This distribution of fat and muscle wasting contributes to the characteristic "moon face" appearance seen in individuals with Cushing's syndrome.
A. Visible swelling of the neck with no pain is not typically associated with Cushing's syndrome. Swelling of the neck may be indicative of other conditions such as goiter or thyroid nodules.
B. Warm, soft, moist, salmon-colored skin is not typically associated with Cushing's syndrome. Instead, individuals with Cushing's syndrome may exhibit thin, fragile, and easily bruised skin due to the effects of cortisol on collagen synthesis and skin integrity.
D. Husky voice and hoarseness are not typically associated with Cushing's syndrome. These symptoms may be indicative of vocal cord dysfunction or other conditions affecting the larynx or vocal cords.
Correct Answer is C
Explanation
C Eating small, frequent meals helps prevent stretching of the stomach pouch created during surgery, reduces the risk of dumping syndrome, and ensures that the body can properly absorb nutrients from the smaller portions of food consumed.
A Reducing the intake of fatty meals is more specific to chronic pancreatitis due to lack of lipases to digest fat.
B While chewing thoroughly is important, it does no specifically apply to gastric bypass surgery.
D Sipping fluids with each meal is recommended after gastric bypass surgery to prevent dehydration and promote hydration. However, it's important for individuals to avoid drinking large amounts of fluids during meals, as this can fill up the smaller stomach pouch quickly, leading to reduced food intake and potential discomfort.
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