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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Wearing braces on both wrists during the night can help maintain a neutral wrist position and alleviate pressure on the median nerve, reducing symptoms of carpal tunnel syndrome.
B. Notifying the healthcare provider may be necessary if symptoms worsen or if additional interventions are needed, but this is not the first-line intervention for managing symptoms at night.
C. Elevating the hands on two pillows at night may provide some relief, but it is not as effective as wearing wrist braces to maintain proper alignment and reduce pressure on the median nerve.
D. Applying cold compresses before bedtime may help reduce inflammation but is not specifically targeted at alleviating nighttime symptoms of carpal tunnel syndrome.
Correct Answer is D
Explanation
A. Increasing anxiety may require intervention, but it does not pose an immediate threat to the client's health compared to other options.
B. Inappropriate laughter could indicate emotional lability, a common symptom in ALS, but it does not typically require immediate intervention unless it's accompanied by other concerning symptoms.
C. Asymmetrical weakness is common in ALS but may not necessarily warrant immediate intervention unless it is significantly affecting the client's ability to perform essential functions.
D. Weakened cough effort is a critical finding in a client with ALS, as it can lead to ineffective airway clearance and increase the risk of aspiration pneumonia. Immediate intervention, such as suctioning or respiratory support, may be necessary to maintain airway patency and prevent complications.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today