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.

Answer and Explanation

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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Correct Answer is D

Explanation

A. Thick skin plaques topped by silvery white scales:
This is a characteristic presentation of psoriasis vulgaris, not an indicator of overexposure to PUVA.

B. Tenderness upon palpation and generalized erythema:
This may be associated with various skin conditions but is not specific to overexposure to PUVA.

C. Brown, rough, greasy, wart-like papules on the face:
This description is not consistent with the expected outcomes or side effects of PUVA treatment.

D. Requires sunglasses because sunlight hurts the eyes.
PUVA treatment involves the use of psoralen, a light-sensitizing medication, followed by exposure to ultraviolet A (UVA) light. Overexposure to PUVA can lead to phototoxic reactions, including eye sensitivity to sunlight (photophobia). If the client requires sunglasses because sunlight hurts the eyes, it suggests that the eyes have been affected by the treatment, and the nurse should intervene to prevent further damage.

A. Evaluate upper and lower extremities for perfusion, pulse volume, and pitting edema. B. Listen for extra heart sounds, murmurs, and rhythm with the bell of the stethoscope. C. Obtain a 12-lead electrocardiogram and begin continuous cardiac monitoring. D. Verify troponin level assessments are scheduled every 3-6 hours for a series of three

Correct Answer is C

Explanation

A. Evaluate upper and lower extremities for perfusion, pulse volume, and pitting edema:
This option focuses on assessing perfusion and circulation in the extremities. While it's important in certain situations, in the context of a client who recently underwent cardiac stent placement and is now experiencing chest pressure and shortness of breath, the priority is to assess the cardiac status more directly.

B. Listen for extra heart sounds, murmurs, and rhythm with the bell of the stethoscope:
This option involves auscultating the heart for abnormal sounds or rhythms. While it's a valuable assessment in general, in this particular scenario, obtaining an electrocardiogram (ECG) and initiating continuous cardiac monitoring would provide a more comprehensive and immediate evaluation of the cardiac status.

C. Obtain a 12-lead electrocardiogram and begin continuous cardiac monitoring:
This is the correct choice. Obtaining a 12-lead ECG and initiating continuous cardiac monitoring is crucial in assessing the client's cardiac function. It allows for the detection of any acute changes in the heart's electrical activity or rhythm, which is essential for timely intervention and management.

D. Verify troponin level assessments are scheduled every 3-6 hours for a series of three:
Monitoring troponin levels is important in assessing cardiac damage, but in this acute situation, obtaining an immediate ECG and initiating continuous cardiac monitoring take precedence for a more real-time evaluation of the client's cardiac status. Troponin levels may be monitored subsequently based on the initial findings.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving a psoralen and ultraviolet A light (PUVA) treatment. Which assessment finding indicates that the client has been overexposed to the treatment?

Correct Answer is D

Explanation

A client who underwent cardiac stent placement four days ago arrives to the emergency department reporting a sudden onset of chest pressure and shortness of breath. Which action should the nurse take next?

Correct Answer is C

Explanation

After falling down the basement steps, a client is brought to the emergency room. X-rays confirms that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?

The nurse is providing teaching to a client with Type 2 diabetes mellitus and peripheral neuropathy. Which information should the nurse provide?

An overweight, young adult client who was recently diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. The client reports feeling very weak and jittery. Which actions should the nurse implement? (Select all that apply.)

A client who was recently diagnosed with Raynaud's disease is concerned about pain management. Which nursing instruction should the nurse provide?

An older adult client with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. The client is anxious and is complaining of a dry mouth. Which intervention should the nurse implement?

While caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?