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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Correct Answer is A

Explanation

A. Restricting protein intake is often recommended for clients with glomerulonephritis to reduce the workload on the kidneys and decrease proteinuria. This can help slow the progression of kidney damage.

B. Increasing intake of high-fiber foods may be beneficial for overall health but is not specifically indicated for glomerulonephritis management.

C. Limiting oral fluid intake to 500 mL/day is not appropriate for most clients and may lead to dehydration, which can exacerbate kidney dysfunction.

D. Increasing intake of potassium-rich foods may be contraindicated in some cases of glomerulonephritis, especially if the client has hyperkalemia. Dietary potassium restriction may be necessary depending on the client's lab values and kidney function.

A. Auscultate the abdomen for bowel sound activity. B. Bring additional sterile dressing supplies to the room. C. Obtain a sample of the drainage to send to the laboratory. D. Prepare the client to return to the operating room.

Correct Answer is D

Explanation

A. Auscultating the abdomen for bowel sound activity is important, but the priority is addressing the dehisced and eviscerated wound.

B. Bringing additional sterile dressing supplies is a good idea, but the priority is addressing the dehisced and eviscerated wound.

C. Obtaining a sample of the drainage for laboratory analysis can wait until the client's immediate needs are addressed.

D. Preparing the client to return to the operating room is the priority to address the dehisced and eviscerated wound and prevent further complications.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is A

Explanation

A client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning the client, the wound dehisces and eviscerates. The nurse moistens an available sterile dressing and places It over the wound. Which intervention should the nurse implement next?

Correct Answer is D

Explanation

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When conducting discharge teaching for a client diagnosed with diverticulosis, which diet instruction should the nurse include?

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