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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Carcinogens are substances that contain cancerous cells:
This statement is incorrect. Carcinogens are substances that have the potential to cause cancer, but they do not necessarily contain cancerous cells themselves.
B. Substances that change a cell so that it becomes cancerous are potential sources of cancer:
This is the correct answer. Carcinogens are agents that can induce changes in the genetic material of cells, leading to the development of cancer. They can initiate or promote the process of carcinogenesis.
C. Environmental factors such as sunlight and chemicals can cause cancer to spread:
This statement is not accurate. Carcinogens can contribute to the initiation or promotion of cancer, but the spread of cancer (metastasis) involves complex biological processes and is not directly caused by environmental factors.
D. Carcinogens are in the environment and cannot be avoided:
This statement is not accurate. While carcinogens may be present in the environment, efforts can be made to minimize exposure and adopt preventive measures. Avoidance of known carcinogens and the promotion of a healthy lifestyle can contribute to cancer prevention.
Correct Answer is ["B","D"]
Explanation
A. Use standard precautions and wear a mask:
The use of standard precautions is appropriate for general care to prevent the transmission of infectious agents. However, specific to MRSA, additional precautions are needed. Wearing a mask is generally not necessary unless the client has respiratory symptoms that warrant respiratory precautions.
B. Institute contact precautions for staff and visitors:
This is a correct intervention. Contact precautions involve using gowns and gloves when providing care to prevent the transmission of MRSA. It is important for both healthcare staff and visitors to adhere to contact precautions to reduce the risk of spreading the infection.
C. Explain the purpose of a low bacteria diet:
The purpose of a low bacteria diet is generally unrelated to the management of MRSA. Low bacteria diets are often recommended for individuals with compromised immune systems to reduce the risk of foodborne infections. However, it may not be directly applicable to MRSA management.
D. Monitor the client's white blood cell count:
Monitoring the white blood cell count is a relevant intervention. An elevated white blood cell count may indicate an ongoing infection or an inflammatory response. Regular monitoring helps assess the client's immune response and the potential severity of the infection.
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