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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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Jogs more frequently than usual daily routine:
Exercise, including jogging, is generally not associated with an increased risk of renal calculi. In fact, regular physical activity can have health benefits.

B. Eats a vegetarian diet with cheese 2 to 3 times a day:
A vegetarian diet alone is not necessarily a risk factor for renal calculi. However, the inclusion of high-oxalate foods, such as certain types of cheese, may contribute to the formation of kidney stones.

C. Experiences additional stress since adopting a child:
Stress is not a direct risk factor for renal calculi. However, certain dietary and lifestyle factors play a more significant role in stone formation.

D. Drinks several bottles of carbonated water daily:
This is the correct answer. Consuming large amounts of carbonated water, especially if it is high in phosphoric acid, can contribute to the formation of kidney stones. Carbonated beverages may increase the excretion of calcium in the urine, potentially leading to stone formation.

A. Minimize symptoms by wearing loose, comfortable clothing B. Sleep without pillows at night to maintain neck alignment. C. Adjust food intake to three full meals per day and no snacks. D. Avoid participation in any aerobic exercise programs

Correct Answer is A

Explanation

A. Minimize symptoms by wearing loose, comfortable clothing:
This is the correct answer. Wearing loose, comfortable clothing can help alleviate pressure on the abdomen, reducing the likelihood of exacerbating GERD symptoms.

B. Sleep without pillows at night to maintain neck alignment:
This recommendation is not specifically related to GERD. In fact, elevating the head of the bed or using extra pillows can be helpful in preventing acid reflux during sleep.

C. Adjust food intake to three full meals per day and no snacks:
It is generally recommended for individuals with GERD to have smaller, more frequent meals rather than three large meals. Eating smaller portions can help reduce the likelihood of gastric distention and reflux.

D. Avoid participation in any aerobic exercise programs:
Exercise is generally beneficial for overall health, but intense aerobic exercise immediately after eating may contribute to GERD symptoms. However, this does not mean avoiding all aerobic exercise. It is more appropriate to advise against vigorous exercise immediately after meals.

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Naxlex Comprehensive Predictor Exams

The nurse is obtaining a health history from a new client who has a history of kidney stones. Which statement by the client indicates an increased risk for renal calculi?

Correct Answer is D

Explanation

Which information should the nurse include in the teaching plan of a client diagnosed with gastroesophageal reflux disease (GERD)?

Correct Answer is A

Explanation

A client is diagnosed with chronic kidney disease and needs to begin dialysis. Which condition entered on the client's medical record should the nurse recognize as a contraindication for peritoneal dialysis?

While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse?

A client with draining skin lesions of the lower extremity is admitted with possible Methicillin-Resistant Staphylococcus Aureus (MRSA). Which nursing interventions should the nurse include in the plan of care? (Select all that apply.)

The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis?

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?

While assessing a client with degenerative joint disease, the nurse observes Heberden's nodes, large prominences on the client's fingers that are reddened. The client reports that the nodes are painful. Which action should the nurse take?