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. Reduced pain in eczematous areas:
While hydration of the skin may contribute to reduced pain in some cases, the primary goal of urea cream is to moisturize and hydrate the skin rather than directly address pain.

B. Healing with a return to normal skin appearance:
Urea cream can contribute to the healing process by hydrating the skin and promoting the removal of dry, scaly skin. However, complete healing and a return to normal skin appearance may also depend on the underlying cause of eczema and other factors.

C. Decreased weeping of ulcerations in affected areas:
Urea cream can help reduce excessive dryness and weeping in eczematous areas by promoting hydration and moisture balance. However, it may not directly address ulcerations, and other interventions may be needed for open wounds.

D. Hydration of affected dry skin areas:
This is the correct answer. Urea is a natural moisturizing factor that helps retain water in the skin. Applying urea cream to affected dry skin areas is expected to hydrate the skin, reduce dryness, and improve the overall moisture balance.

A. Measure the client's blood pressure. B. Remove all of the morphine patches. C. Apply oxygen per face mask. D. Administer a narcotic antagonist.

Correct Answer is D

Explanation

A. Measure the client's blood pressure:
While monitoring blood pressure is an important aspect of assessing a client's overall condition, it is not the immediate priority in a suspected opioid overdose. Respiratory depression and difficulty in arousing are more critical concerns that warrant prompt intervention with naloxone.

B. Remove all of the morphine patches:
While eventually, the nurse will need to address the presence of multiple morphine patches, removing them is not the first action. Administering naloxone to reverse the opioid effects takes precedence over patch removal.

C. Apply oxygen per face mask:
While providing oxygen may be necessary to support respiratory function, it doesn't address the underlying cause of the respiratory distress, which is likely opioid toxicity. Administering naloxone is the more direct and immediate intervention to counteract the effects of the opioids.

D. Administer a narcotic antagonist:
This is the correct and immediate priority. If the client is difficult to arouse and has multiple morphine patches, it raises concerns about opioid toxicity. Naloxone is a narcotic antagonist that can reverse the effects of opioid overdose, particularly respiratory depression, and is crucial in this scenario to restore normal respiratory function.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with eczema is applying 10% urea cream onto the affected skin areas. Which finding reflects the expected therapeutic response?

Correct Answer is D

Explanation

A client with lung cancer who wears a subcutaneous morphine sulfate patch for pain is short of breath and is difficult to arouse. When performing a head to toe assessment, the nurse discovers four analgesic patches on the client's body. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

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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?

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