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.

Medicate for pain and monitor vital signs according to protocol.

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

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

Answer and Explanation

The Correct Answer is B

A. Administer IV fluid bolus as prescribed by the healthcare provider is not the priority unless there is evidence of hypovolemia or shock, which isn't indicated by the current vital signs alone.

B. Medicate for pain and monitor vital signs according to protocol is the most important intervention. The client's elevated heart rate, respiratory rate, and blood pressure are likely due to inadequate pain control following a thoracotomy, a major surgical procedure known for causing significant postoperative pain. Managing the pain is crucial because uncontrolled pain can lead to increased sympathetic nervous system activity, resulting in tachycardia, hypertension, and tachypnea. Addressing the pain effectively will help stabilize these vital signs.

C. Encourage the client to splint the incision with a pillow to cough and deep breathe is an important postoperative intervention to prevent complications such as atelectasis, but it should be done after pain is adequately controlled, as pain can inhibit the ability to deep breathe and cough effectively.

D. Apply oxygen at 10 L/minute via non-rebreather mask and monitor pulse oximeter may be necessary if there are signs of hypoxia. However, the vital sign changes here are more likely related to pain rather than respiratory distress, making pain management the immediate priority.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Having the client sign surgical and transfusion permits is important but not the priority in this situation.

B. Notifying the healthcare provider of the client's medication history, including heparin use, is crucial to ensure appropriate perioperative management and to prevent excessive bleeding during surgery.

C. Explaining the potential for bleeding to the client is important for informed consent but is not the priority in this situation.

D. Observing the heparin injection sites for signs of bruising is important but not the priority compared to notifying the healthcare provider about the client's medication history.

A. Obesity B. Hypertension C. Drinks beer nightly D. Daily aspirin E. Type 2 diabetes mellitus F. Sleep apnea G. Ibuprofen for pain H. Nonsmoker I. Osteoarthritis

Correct Answer is ["A","B","C","D","E","F"]

Explanation

A. Obesity is a significant risk factor for gout as it can increase uric acid production and decrease its excretion.

B. Hypertension is commonly associated with gout, potentially due to shared risk factors including kidney health and certain medications that can raise uric acid levels.

C. Alcohol, especially beer, is a well-known trigger for gout attacks because it increases uric acid production and reduces its excretion.

D. Low doses of aspirin can increase uric acid levels by reducing its excretion through the kidneys.

E. While not a direct risk factor, type 2 diabetes is often associated with metabolic syndrome, which includes several risk factors for gout.

F. Research suggests a link between sleep apnea and increased risk of gout, possibly through the effects of intermittent hypoxia on uric acid levels.

G. Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen are typically used to treat gout attacks and do not generally increase the risk of developing gout. They can, however, affect kidney function with prolonged use.

H. Smoking is not directly linked to gout risk; smoking cessation is generally beneficial for overall health but does not increase gout risk.

I. Osteoarthritis is a different type of joint disease and does not increase the risk of developing gout.

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

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","C","D","E","F"]

Explanation

Patient Data Exhibits The nurse has identified the priority problem for the client and now must determine proper care interventions. Based on the client history and the assessment data, what action(s) should the nurse anticipate? Select all that apply.

The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?

The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?

Exhibits Select the 3 dietary choices that are not part of the recommended diet for a client with gout.

A college student comes to the school's health clinic troubled by urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first?

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?

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.