The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes the following vital signs: heart rate 140 beats/minute, respirations 26 breaths/minute, and blood pressure 140/90 mmHg. Which intervention is most important for the nurse to implement?
Administer intravenous fluid bolus as prescribed by the healthcare provider.
Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter.
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.
The Correct Answer is B
A. Administer intravenous fluid bolus as prescribed by the healthcare provider.
While hydration is important, the vital signs provided (elevated heart rate and respiratory rate) are more indicative of potential respiratory distress. Administering fluids may be indicated in certain situations, but it may not address the immediate concern of compromised oxygenation.
B. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter.
This is the correct choice. The client's elevated heart rate and respiratory rate suggest the need for improved oxygenation. Applying oxygen at a high flow rate via a non-rebreather mask is an immediate intervention to address potential respiratory compromise. Monitoring the pulse oximeter provides real-time feedback on oxygen saturation.
C. Medicate for pain and monitor vital signs according to protocol.
Pain management is an important aspect of post-operative care, but the immediate concern in this scenario is the potential for respiratory distress. Administering pain medication alone may not address the primary issue.
D. Encourage the client to splint the incision with a pillow to cough and deep breathe.
While encouraging the client to cough and deep breathe is important for post-thoracotomy care, the elevated vital signs suggest a need for more immediate intervention to ensure adequate oxygenation. Applying oxygen and monitoring the pulse oximeter take precedence.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Guidelines for oxygen use:
While guidelines for oxygen use are important, addressing the root cause of the respiratory condition, which includes smoking cessation, is crucial for long-term management.
B. Methods for weight loss:
Obesity can contribute to respiratory issues, but in the immediate context of emphysema exacerbation and the need for oxygen therapy, smoking cessation is a more urgent concern.
C. Approaches to conserve energy:
Conserving energy is important for clients with emphysema, but addressing the impact of smoking on respiratory function is a more immediate priority.
D. Strategies for smoking cessation.
Smoking is a major contributor to the progression of emphysema and exacerbation of respiratory symptoms. Addressing smoking cessation is crucial in improving the client's respiratory function and overall health. Continuing to smoke can exacerbate emphysema and compromise the effectiveness of other interventions, including oxygen therapy.
Correct Answer is D
Explanation
A. Blood pH level:
The blood pH level is important for assessing the acid-base balance in the body. However, in the context of purulent drainage from a wound, it is not the primary laboratory value to review for signs of infection.
B. Platelet count:
Platelet count is important for assessing blood clotting ability. While it is a valuable parameter in overall care, it may not be directly related to the observation of purulent drainage from a wound, which typically suggests infection rather than a clotting issue.
C. Hematocrit:
Hematocrit measures the proportion of blood that is cellular. Like platelet count, it is important for assessing overall blood composition and oxygen-carrying capacity. However, it may not be the first parameter to review when evaluating signs of infection.
D. White blood cell (WBC) count:
The WBC count is a crucial parameter when assessing for infection. An elevated WBC count is a common response to infection as the body mobilizes its immune defenses. Reviewing the WBC count is particularly relevant when purulent drainage is observed, as it may indicate an inflammatory response to infection.
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